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The  Tuberculosis  Problem 
in  Rhode  Island 


Ml 


1920 


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THE  TUBERCULOSIS  PROBLEM 
IN  RHODE  ISLAND 

A  Survey  Conducted  for  the 
Rhode  Island  Tuberculosis  Association 

BY 

C.-E.  A.  WINSLOW,  Dr.P.H. 
Professor  of  Public  Health,  Yale  School  of  Medicine 

ASSISTED  BY 

WILLIS  E.  CHANDLER 


1920 


Cbe  (Providence  Ipress: 
Snow  &  Farnham  Co.,  Printers 


November  24,  1920 
Mr.  Frank  N.  Phillips, 

President,  Rhode  Island  Tuberculosis  Association, 
Providence,  R.  I. 
Dear  Mr.  Phillips: 

I  am  enclosing  herewith  a  report  on  the  tuberculosis  problem  in 
Rhode  Island,  prepared  in  accordance  with  a  request  made  last 
spring  by  the  executive  committee  of  the  Rhode  Island  Tubercu- 
losis Association. 

I  have  attempted  in  the  survey,  upon  which  this  report  is  based, 
to  estimate  the  extent,  and,  so  far  as  possible,  the  character,  of  the 
anti-tuberculosis  work  carried  on  by  various  agencies  in  the  State 
and  to  measure  this  work  by  objective  quantitative  standards.  I 
have  made  four  visits  to  Rhode  Island,  spending  two  days  in  the 
State  on  each  occasion  and  have  visited  the  principal  clinics,  hos- 
pitals and  nursing  centers  of  the  State  and  interviewed  the  leaders 
in  the  anti-tuberculosis  movement  in  Providence,  Pawtucket,  Woon- 
socket,  Newport,  the  Pawtuxet  Valley  and  Wallum  Lake.  The 
statistical  material  has  been  prepared  in  accordance  with  my  sug- 
gestions by  Mr.  Willis  E.  Chandler,  the  executive  secretary  of  your 
association,  and  I  wish  to  express  my  warm  appreciation  of  the 
faithful  and  effective  work  which  he  has  done  in  collecting  and  analyz- 
ing it.  I  wish  also  to  record  my  gratitude  for  the  assistance  rendered 
by  the  officials  of  the  State  Board  of  Health,  the  State  Sanatorium 
at  Wallum  Lake,  the  City  Health  Department  of  Providence,  the 
Providence  District  Nursing  Association,  the  Providence  Tubercu- 
losis League,  and  of  many  other  medical  and  nursing  organizations 
throughout  the  State,  who  have  courteously  furnished  me  with 
data,  in  some  cases  at  very  considerable  expenditure  of  time  and 
trouble. 

On  the  basis  of  my  findings  I  have  attempted  to  formulate  a  gen- 
eral program  for  the  development  of  anti-tuberculosis  work  in 
Rhode  Island,  which  I  trust  may  receive  the  consideration  of  your 
association,  and  of  the  other  official  and  private  agencies  engaged  in 
this  campaign.  I  believe  that  the  suggestions  made  are  moderate 
and  conservative;  but  I  think  that,  if  adopted,  they  will  lay  the 
foundation   for  the  development  of  an  anti-tuberculosis  program 


in  advance  of  any  that  has  yet  been  carried  out  on  a  state-wide 
basis.  Rhode  Island  has  unusual  opportunities  for  building  a  com- 
plete tuberculosis  program,  in  view  of  its  excellent  sanatorium  and 
of  the  fine  clinic  and  nursing  service  which  has  been  organized  in 
the  city  of  Providence.  These  opportunities  are  not,  however,  at 
present  fully  utilized  and  the  unusually  high  tuberculosis  death  rate 
of  the  State  makes  it  imperatively  necessary  that  action  should  be 
taken  to  improve  existing  conditions.  Rhode  Island  has  the  oppor- 
tunity to  set  an  example, — to  show  what  can  really  be  accomplished 
in  the  saving  of  human  life  by  a  co-ordinated  and  effective  modern 
anti-tuberculosis  program.  If  your  association  can  secure  the  co- 
operation of  the  State  and  local  officials,  and  of  the  private  agencies, 
in  bringing  about  this  result  it  will  have  rendered  a  great  service, 
not  only  to  the  State  but  to  the  country  as  a  whole. 

Yours  very  sincerely, 

C.-E.  A.  WINSLOW. 

I.  THE  PRESENT  STATUS  OF  THE  CAMPAIGN  AGAINST 
TUBERCULOSIS. 

The  official  campaign  against  tuberculosis  in  the  United  States 
began  in  organized  and  definite  fashion  with  the  program  formu- 
lated (under  the  inspiration  of  Dr.  Hermann  Biggs)  by  the  New 
York  City  Health  Department  in  1894.  The  movement  spread  be- 
yond the  field  of  administrative  effort  and  became  a  far-reaching 
popular  propaganda,  with  the  organization  of  the  National  Tuber- 
culosis Association  in  1904. 

At  the  time  the  national  association  was  formed  the  attempt  to 
control  tuberculosis  was  regarded  as  on  the  road  to  phenomenal  suc- 
cess. The  death-rate  from  all  forms  of  this  disease  in  the  Regis- 
tration Area  had  decreased  from  326.2  in  1880  to  201.2  in  1900. 
Dr.  Samuel  W.  Abbot,  Secretary  of  the  Massachusetts  State  Board 
of  Health,  predicted  that  tuberculosis  sanatoria  would  some  day 
remain,  like  the  pest-houses  of  the  middle  ages,  as  monuments  to 
a  disease  which  was  only  of  historical  interest.  Today  the  situa- 
tion is  a  very  different  one.  The  reduction  in  the  death-rate  has 
slackened.  A  remarkable  drop  did  indeed  take  place  in  1919,  for 
reasons  which  cannot  be  evaluated  until  full  statistical  data  for 
both  1919  and  1920  are  available.  Between  1910  and  1918,  how- 
ever, the  rate  for  the  Registration  Area,  for  tuberculosis  of  all 

3 


forms,  fell  only  from  160.3  to  148.0.  A  certain  apathy  has  crept 
over  the  unofficial  organizations  created  to  deal  with  this  problem; 
and  the  healthy  departments  of  most  states  and  cities  place  little 
stress  upon  this  disease  in  their  administrative  programs.  Among 
leading  experts  on  tuberculos's  there  has  developed  an  attitude  of 
uncertainty  in  regard  to  the  fundamental  scientific  basis  of  the 
whole  campaign  against  this  disease, —  a  tendency  to  attribute  past 
reductions  to  hypothetical  alterations  in  the  biological  character- 
istics of  the  tubercle  bacillus  or  the  human  being  or  to  general  al- 
terations in  social  and  economic  conditions, — and  a  scepticism  as 
to  the  feasibility  of  taking  any  definite  steps  at  all  toward  the  pur- 
poseful control  of  tuberculosis. 

A  full  survey  of  available  scientific  knowledge,  and  of  accumu- 
lated practical  experience,  does  not  appear  to  justify  an  attitude  of 
non  possumus.  It  seems  clear  from  recent  researches  that  in  most 
urban  and  semi-urban  communities  the  vast  majority  of  children 
acquire  infection  with  human  or  bovine  tubercle  bacilli  before  the 
age  of  fifteen  years.  A  certain  proportion  succumb  to  massive  in- 
fection during  this  period,  since  in  individuals  unprotected  by  mild 
chronic  infection  tuberculosis  runs  a  rapid  and  fatal  course.  The 
actual  number  of  deaths  from  tuberculosis  of  all  forms  in  New  York 
City  between  1913  and  1917  was  greater  under  1  year  of  age  than 
for  any  other  year  of  life  outside  of  the  quinquennium,  thirty-five 
to  thirty-nine.  In  England  and  Wales,  for  the  same  period,  the 
number  of  deaths  under  1  year  of  age  was  vastly  in  excess  of  that 
recorded  for  any  other  year  of  life.  Individuals  who  do  not  suc- 
cumb in  infancy  or  childhood  acquire  a  relative  immunity;  and 
tuberculosis  in  adult  life  results  from  a  breakdown  of  this  immunity, 
due  to  a  lowering  of  general  vital  resistance,  or  perhaps  to  an  un- 
duly heavy  new  infection  from  without.  We  may  avoid  on  the 
one  hand  the  extreme  view  that  tuberculosis  in  adults  is  never  due 
to  fresh  infection  of  external  origin;  and  we  may  perhaps  doubt  the 
supreme  importance  placed  on  the  hospital  isolation  of  advanced 
cases  by  others.  The  safe  middle  course  is  to  conclude  that  ex- 
posure to  massive  infection,  either  with  the  human  or  the  bovine 
bacillus,  is  probably  dangerous  to  adults  and  is  certainly  dangerous 
to  children.  In  order  to  deal  effectively  with  this  factor  of  infec- 
tion we  need  to  secure: 

(a)  The  pasteurization  of  all  milk  used  by  children,  except  that 
from  tuberculin-tested  herds. 


(b)  The  education  of  all  open  human  cases  of  tuberculosis  in 
regard  to  the  steps  necessary  for  the  protection  of  family  and  asso- 
ciates from  infection. 

(c)  The  provision  of  hospitals  for  the  care  of  patients  who  can- 
not be  kept  at  home  without  danger  to  others,  and  particularly  to 
children. 

(d)  The  forcible  isolation  of  the  few  indi\iduals  who  wilfully 
or  carelessly  fail  to  take  the  precautions  necessary  for  the  safe- 
guarding of  others. 

Passing  from  the  problem  of  infection  to  that  of  resistance,  it  is 
clear  that  in  settled  communities  the  vast  majority  of  healthy  adults 
have  acquired  a  relative  immunity  to  tuberculosis  and  it  is  highly 
probable  that  a  failure  of  vital  resistance  is  in  most  cases  the  de- 
termining factor,  which  transforms  a  latent  infection  into  active 
clinical  disease.  Overwork,  underfeeding,  illness  of  other  types, 
alcoholism,  industrial  dusts,  these  are  the  chief  agents  which  cause 
the  lighting  up  of  isolated  local  lesions  into  an  acute  disease  process. 
In  dealing  with  adult  tuberculosis,  in  communities  where  tubercu- 
lous infection  is  common,  the  development  of  general  and  individual 
resistance  is  our  chief  weapon.  The  following  measures  are  essen- 
tial to  this  portion  of  the  program: 

1.  For  the  community  as  a  whole; 

(e)  The  building  up  of  vital  resistance  among  the  individual 
members  of  thecommunity  by  maintaininga  high  social  and  economic 
standard  of  li^'ing. 

(f)  The  dissemination  of  knowledge  in  regard  to  personal 
hygiene,  including  the  hygiene  of  nutrition,  air  conditioning,  exer- 
cise and  rest,  and  of  a  knowledge  of  the  early  signs  and  warnings  of 
tuberculous  disease. 

(g)  The  control  of  industrial  processes  which  invoke  the  ex- 
posure of  the  worker  to  hard  crystalline  dusts,  a  hazard  of  the  first 
importance  as  a  contributory  factor  in  tuberculosis, 

2.  For  the  infected  individual; 

(h)  The  prompt  detection,  through  skilled  pri\ate  medical  at- 
tendance and  ani|)le  free  dispensary  service,  of  cases  of  tubercu- 
losis in  their  early  and  curable  stages. 


(i)  Organized  machinery  for  searching  out  probably  infected 
individuals  in  the  entourage  of  known  cases  and  for  bringing  such 
individuals  to  physicians  or  dispensaries  for  prompt  examination. 

(j)  The  systematic  supervision  of  patients  living  in  their  homes, 
through  regular  contact  with  dispensaries  and  through  regular  visits 
for  home  instruction  by  trained  public  health  nurses. 

(k)  Sanatorium  treatment  for  all  patients  who  cannot  main- 
tain a  high  standard  of  hygienic  living  in  the  home. 

(1)  Supervision  by  public  health  nurses  of  all  cases  discharged 
from  sanatoria  and  the  provision  for  such  cases  of  an  environment 
in  which  normal  family  life  may  be  maintained  with  a  maximum 
of  self-support,  and  yet  in  a  physical  and  social  environment  which 
permits  and  facilitates  hygienic  living. 

The  program  outlined  above  is  essentially  implied  in  the  more 
modern  legislation  regarding  tuberculosis.  Thus  Sir  Arthur  News- 
holme  (Public  Health  and  Insurance)  says, 

"Under  the  English  Tuberculosis  Regulations  the  medical  officer  of  health 
or  an  officer  of  the  local  authority  acting  under  his  instructions  is  required  to 
make  such  inquiries  and  take  such  steps  as  may  be  necessary  or  desirable  for 
investigating  the  source  of  infection,  for  preventing  the  spread  of  infection, 
and  for  removing  conditions  favourable  to  infection.  The  action  required  in- 
cludes inter  alia 

1.  Attention  to  the  personal  hygiene  of  the  patient,  including  instruction 
in  the  necessary  precautions  as  to  coughing  and  expectoration. 

2.  Any  assistance  needed  to  ensure  for  the  patient 

(a)  Skilled  medical  attendance  and   nursing  as  required  while  he  is 

treated  at  home; 

(b)  Institutional  treatment  when  required; 

(c)  Supplementation  of  the  convalescent  patient's  funds,  when  needed, 

to  obviate  the  necessity  for  him  at  once  to  embark  in  full-time 
work;  to  provide  additional  bedroom  accommodation  when 
needed;  and  to  ensure  that  the  patient  and  his  family  are  not 
undernourished  or  overworked. 

3.  Remedial  action  for  any  insanitary  conditions  of  the  home,  such  as  un- 
cleanliness,  dampness,  overcrowding;  or  of  the  patient's  workplace,  especially 
for  dusty  occupations. 

4.  Examination  of  home  contacts  with  the  patient." 

As  yet  however  such  a  program  remains  little  more  than  a  counsel 
of  perfection, — at  least  in  the  United  States.  We  are  not  securing 
general   pasteurization   of  milk.     We  are  not  controlling  careless 


consumptives,  or  officially  supervising  tuberculous  patients  of  any 
group.  We  are  not  systematically  detecting  incipient  tuberculosis. 
We  are  getting  our  cases  into  sanatoria  too  late,  and  sending  them 
out  too  early.  We  are  failing  to  provide  the  essential  conditions  of 
after  care.  We  may  say  of  the  anti-tuberculosis  program  as  the 
philosopher  said  when  told  that  Christianity  had  failed,  "It  has  not 
failed.     It  has  never  been  tried." 

The  Health  and  Community  Demonstration  at  Framingham, 
Massachusetts,  is  the  first  thoroughgoing  attempt  to  carry  out  a 
complete  anti-tuberculosis  program;  and  the  death  rate  in  Framing- 
ham  has  fallen  from  121.5  between  1907  and  1916  to  79.8  for  1917- 
1920.     (Last  four  months  of  1920  missing.) 

The  results  obtained  in  this  instance  are  not  as  yet  conclusive; 
for  the  period  of  four  years  is  too  short  to  avoid  the  possibility  of 
statistical  errors  in  so  small  a  community.  Yet,  as  they  stand,  the 
Framingham  data  are  most  encouraging;  and  they  are  in  entire 
accord  with  the  conclusions  to  be  drawn  from  a  consideration  of 
the  whole  body  of  our  present  knowledge.  The  general  program 
outlined  above  is  indicated,  by  theoretical  considerations  and  prac- 
tical experience,  as  essential  to  success  in  dealing  with  tuberculosis,, 
and  as  calculated  to  bring  definite  and  tangible  results  if  carried  out 
with  reasonable  effectiveness. 


II.     THE    INCIDENCE    OF    TUBERCULOSIS    IN    RHODE 

ISLAND. 

Tuberculosis  (of  all  forms)  caused  between  10.4  and  11.0  per  cent 
of  all  the  deaths  in  the  state  of  Rhode  Island  for  each  of  the  eight 
years,  1910  to  1917.  In  1918  the  ratio  fell  to  8.6  per  cent  on  ac- 
count of  the  large  number  of  deaths  from  influenza  and  pneumonia. 
In  this  latter  year  (1918)  tuberculosis  was  the  third  greatest  factor 
in  the  death-rate.  In  1912,  1914,  1915  and  1916  it  stood  second  to 
heart  disease.  In  1910,  1911,  1913  and  1917  it  caused  more  deaths 
than  any  other  disease.  The  control  of  tuberculosis  continues  there- 
fore to  be  a  social  problem  of  the  first  magnitude. 

In  attempting  an  exact  analysis  of  tuberculosis  mortality  in 
Rhofle  Island  we  were  confronted  by  serious  difficulties,  since  both 
of  the  factors  upon  which  mortality  tables  depend, — population  and 
reports  of  deaths, — were  subject  to  some  uncertaint>-. 


In  estimating  the  population  of  the  state  and  of  its  various  pohti- 
cal  divisions  we  have  at  our  disposal  the  results  of  three  censuses, 
the  Federal  censuses  of  1910  and  1920,  and  the  State  census  of  1915. 
The  Federal  census  of  1910  indicated  a  total  population  for  the 
state  of  542,610.  The  state  census  of  1915,  which  local  authorities 
believe  was  conducted  in  a  thorough  and  conservative  fashion,  gave 
the  state  a  population  of  595,986,  an  increase  of  53,000  in  five  years. 
The  Federal  census  of  1920  revealed  a  population  of  604,397,  an  in- 
crease of  less  than  9000  for  the  second  quinquennium.  The  accu- 
racy of  the  1920  enumeration  is  questioned  by  local  authorities  and 
it  is  believed  by  many  that  on  account  of  the  severe  winter  weather 
during  which  the  count  was  made  many  individuals  and  families 
were  overlooked.  In  estimating  the  populations  for  intervening 
years  one  might  compute  from  the  1910  and  1915  enumerations, 
ignoring  the  last  Federal  census,  or  from  the  two  Federal  censuses 
alone,  ignoring  the  State  census,  or  one  might  use  all  three.  I  have 
chosen  the  latter  course  as  the  lesser  of  three  evils,  feeling  that  the 
Federal  census  of  1920  could  scarcely  be  dismissed  from  considera- 
tion since  it  will  certainly  be  used  for  offtcial  statistical  analj^ses  in 
the  future.  On  the  other  hand  there  seems  good  reason  to  believe 
that  the  State  census  of  1915  was  essentially  correct.  The  popula- 
tion for  each  administrative  unit  for  the  years  1910  to  1920  has 
therefore  been  computed  by  Mr.  Chandler  on  an  arithmetical  basis, 
using  all  three  enumerations,  and  the  results  are  presented  in  Table 
I  below.  The  effect  of  the  discordant  results  of  the  two  last  cen- 
suses is  of  course  to  produce  the  effect  of  a  rapid  rate  of  increase  in 
population  between  1910  and  1915  (about  10,000  a  year  for  the 
state  as  a  whole)  with  a  slow  rate  of  increase  between  1915  and  1920 
(less  than  2000  a  ^ear  for  the  state  as  a  whole).  For  the  city  of 
Providence  an  increase  of  4600  a  year  is  indicated  for  the  first  quin- 
quennium, and  a  decrease  of  2000  for  the  second  quinquennium.  It 
is  possible  that  this  represents  fairly  well  the  actual  facts,  since  vital 
statisticians  recognize  a  similar  reduction  in  the  normal  growth  of 
the  population  of  other  states  and  cities  as  a  result  of  decreased 
immigration,  and  increased  mortality  due  to  the  war  and  the  in- 
fluenza epidemic.  The  results  of  the  computation  of  population 
made  by  Mr.  Chandler  on  the  basis  of  the  three  censuses  are  pre- 
sented in  Table  I. 

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xco-*oc-^>-ioo-xcJcoxcococr. 


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Our  second  problem  was  to  determine  the  number  of  deaths  from 
tuberculosis  which  could  properly  be  credited  to  each  political  unit 
for  each  of  the  years  covered  by  our  study.  In  order  to  obtain 
accurate  data  it  was  necessary  to  redistribute  the  deaths  occurring 
in  institutions  for  the  care  of  tuberculosis,  so  that  they  might  be 
charged  to  the  city  or  town  where  the  patient  resided  and  was 
taken  ill.  Mr.  Chandler  has  therefore  gone  over  in  detail  all  the 
records  for  the  past  ten  years  at  Wa  lum  Lake,  Hillsgrove  and  Crans- 
ton, and  at  the  City  and  Rhode  Island  Hospitals  in  Providence 
and,  after  assigning  each  death  to  its  place  of  legal  residence,  has 
obtained  the  data  presented  in  Table  II,  which  we  believe  give  a 
true  picture  of  the  actual  variations  in  the  ncidence  of  tuberculosis 
within  the  state. 

In  order  to  gain  an  idea  of  the  general  incidence  of  tuberculosis 
in  Rhode  Island  we  have  compared  the  figures  for  each  year  with 
corresponding  statistics  for  the  Registration  Area  in  general  and  for 
the  State  of  Connecticut,  which  should  furnish  a  reasonably  fair 
basis  of  comparison  on  account  of  general  similarity  in  climate  and 
in  racial  and  social  and  economic  conditions. 


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II 


170 

169 

182 

147 

139 

153 

146 

116 

142 

146 

148 

TABLE  III. 
Mortality  from  All  Forms  of  Tuberculosis  in  Rhode  Island,  in  Con- 
necticut, AND  in  the  Registration  Area. 
Deaths  per  100,000. 
Year  1910     1911     1912     1913     1914     1915     1916     1917     1918     1919 

R.  I.  181       172       160       164       160       159 

Conn.  150       148       142       140       146       139 

Reg.  Area        160       159       149       148       147       146 

Table  III  and  Fig.l  indicate  a  marked  and  continuous  excess  in 
the  tuberculosis  death  rate  of  Rhode  Island,  as  compared  with  both 
the  State  of  Connecticut  and  the  Registration  Area  as  a  whole.  In 
view  of  the  assumption  that  the  1920  populat'on  estimates  were  ab- 
normally low  I  have  calcu'ated  what  the  population  of  the  state 
would  have  been  in  1919  if  the  rate  of  increase  indicated  by  the  1910 
and  1915  censuses  had  been  continued.  Using  the  annual  incre- 
ment of  10,675  indicated  by  the  two  earlier  enumerations  we  ob- 
tain the  folowing  populations:  1916,  606,661 ;  1917,  617,336;  1918, 
628.011 ;  1919,  638,686.  On  the  basis  of  these  populations  we  have 
computed  the  mortality  rates  indicated  for  1916-1919  by  the  dotted 
lines  in  F'g.  1.  E^ven  on  this  basis  it  is  clear  that  the  tuberculosis 
death-rate  of  Rhode  Island  has  been  consistently  about  20  per 
100,000  higher  than  that  for  the  State  of  Connecticut  or  the  Regis- 
tration Area  as  a  whole.  It  is  very  probable  that  this  excess  is  due 
to  differences  in  racial,  social  or  economic  conditions  rather  than  to 
relative  inadequacy  in  the  machinery  available  for  combating  the 
disease.  Rhode  Island  is  an  intensively  urban  state  with  an  un- 
usually large  foreign  born  population.  According  to  the  1910 
census,  for  example,  67.7  per  cent  of  the  population  of  Rhode  Island 
lived  in  cities  of  over  25,000  population  against  48.5  per  cent  ki  the 
case  of  Connecticut;  while  native  whites  of  native  parentage  made 
up  a  smaller  proportion  of  the  population  (29.5  per  cent  against 
35.^  per  cent)  native  whites  of  foreign  or  mixed  parentage  a  larger 
proportion  (35.9  per  cent  against  33.6  per  cent),  and  foreign  born 
whites  a  larger  proportion  (32.8  per  cent  against  29.5  per  cent); 
Rhode  Island  in  each  case  being  compared  with  Connecticut. 

Whatever  may  be  the  cause  of  the  conditions  which  exist,  the 
problem  remains;  and  it  is  clear  that  Rhode  Island  faces,  in  dealing 
with  tuberculosis,  a  problem  which  is  not  only  intrinsically  of  large 
magnitude  but  one  which  is  relatively  more  serious  than  that  of 
neighboring  states. 

12  ■ 


FIG.  I. 


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13 


In  order  to  indicate  more  clearly  the  variations  in  incidence  of 
tuberculosis  among  the  various  political  subdivisions  of  the  state 
the  rates  for  the  six  principal  cities  and  for  the  rest  of  the  state  have 
been  computed  in  Table  IV  for  the  two  quinquennia,  1910-1914 
and  1915-1919,  and  for  the  whole  decennial  period.  It  appears 
from  these  figures  that  the  rate  in  Providence  has  been  materially 
higher  than  that  recorded  for  any  other  section  of  the  state  (196) 
with  Woonsocket  second  (173),  and  Central  Falls  (165),  and  Paw- 
tucket  (158)  third  and  fourth  respectively.  The  combined  smaller 
towns  of  the  state  have  a  rate  well  below  the  average  (137),  while 
Newport  (132)  and  Cranston  (96)  exhibit  an  even  more  favorable 


TABLE  IV. 
Average  Death  Rate  from  all  Forms  of  Tuberculosis. 


Provi- 

Paw- 

Woon- 

New- 

Crans- 

Central 

Rest  of 

dence 

tucket 

socket 

port 

ton- 

Falls 

State 

1910-1914 

194 

171 

176 

133 

100 

165 

141 

1915-1919 

199 

145 

170 

131 

93 

166 

133 

1910-1919 

196 

158 

173 

132 

96 

165 

137 

record.  Marked  reductions  in  the  second  quinquennium,  as  com- 
pared with  the  first,  are  shown  only  in  Pawtucket,  the  small  towns, 
and  Cranston.  Pawtucket  is  one  of  the  few  areas  in  the  state 
which  showed  a  marked  gain  in  population  in  1920,  and  if  this  census 
was  greatly  in  error  in  Providence,  Woonsocket  and  Central  Falls, 
but  not  in  Pawtucket,  the  observed  differences  would  be  in  part  ex- 
plained. The  data  for  the  quinquennium  1910  to  1914  are  in  any 
case  of  unquestioned  validity  and  they  indicate  exactly  the  same 
relative  rank  for  the  six  cities  as  the  figures  for  the  whole  period. 

It  can  not  be  in  any  way  concluded  that  the  high  death  rates 
from  tuberculosis  in  the  four  cities  which  lead  in  Table  IV  is  due  to 
special  neglect  of  anti-tuberculosis  measures.  On  the  contrary 
Providence  is  better  equipped  with  anti-tuberculosis  machinery 
than  any  other  city  and  Pawtucket  and  Woonsocket  are  better  off 
than  Newport  or  Cranston.  The  actual  fact  appears  to  be  that 
clinical  and  nursing  services  have  been  provided  most  freely  where 
the  need  was  most  acute,  but  have  not  yet  been  provided  anywhere 
in  sufficiently  effective  concentration  to  effect  a  material  impression 
upon  the  mortality  rates.  It  is  also  probable  that  the  recognition 
of  tuberculosis  is  better  in  the  cities  and  that  the  death  rates  would 

14 


be  higher  in  the  small  towns  if  all  deaths  really  due  to  tuberculosis 
were  diagnosed  as  such. 

In  general,  the  variations  in  tuberculosis  mortality  correspond 
closely  to  general  social  and  economic  conditions.  Providence  is 
most  highly  urbanized  and  industrialized  and  shows  the  highest 
rate.  Pawtucket,  Central  Falls  and  Woonsocket  naturally  fall  in 
a  second  group,  while  Newport  and  the  rest  of  the  state  are  perhaps 
characterized  by  a  more  favorable  economic  status  and  are  relatively 
free  from  the  unfavorable  conditions  of  urban  life.  Assuming,  as  I 
do,  that  the  basis  of  the  anti-tuberculosis  movement  is  funda- 
mentally a  sound  one,  two  conclusions  would  seem  warranted. 


15 


FIG.  II. 
Tuberculosis  Death  Rates  (per  100,000)  Principal  Cities. 
Providence     Pawtucket     Woonsocket      Newport       Cranston     Central  Falls    Rest  of  State 
199 


194 


176 


145 


170 


133 


131 


lOO 


93 


165, 'QS 


141 


133 


1910  1915 

1910  1915 

1910  1915 

1910  1915 

1910  1915 

1910  1915 

1910  1915 

to   to 

to   to 

to   to 

to   to 

to   to 

to   to 

to   to 

1914  1919 

1914  1919 

1914  1919 

1914  1919 

1914  1919 

1914  1919 

1914  1919 

i6 


First,  the  four  largest  cities  which  are  now  carrying  out  organized 
anti-tuberculosis  work  must  increase  its  volume,  and  improve  its 
efficiency,  if  they  are  to  cope  with  the  peculiarly  difficult  problems 
created  by  urban  and  industrial  conditions.  I  know  of  no  funda- 
mental reason  why  Providence  should  suffer  from  a  higher  rate  than 
other  eastern  cities  of  similar  size.  Table  V  and  Fig.  3  show  the 
quinquennial  averages  for  New  York  City  and  for  Providence,  New 
Haven,  Rochester  and  Syracuse,  cities  of  the  same  general  class. 
Providence  stood  second  to  New  York  only,  in  1910  to  1914  and  has 
increased  its  rate  from  1915  to  1919,  while  New  York  shows  a  sub- 
stantial decrease.  All  the  other  three  cities  were  well  below  Provi- 
dence in  1910  to  1914  and  exhibit  definite  reductions  from  1915  to 
1919. 

TABLE  V. 
Comparison  of  Tuberculosis  Mortality  (all  forms)  in  Providence  and 

IN  certain   other  eastern  cities. 
City  New  York 

Death  rate         City  Provid&nce      New  Haven       Rochester         Syracuse 

1910-1914  200  194  149  127  116 

1915-1919  172  199  134  111  105 


»7 


FIG.  III. 
Tuberculosis  Death  Rates  (per  100,000) 

New  York     New  Haven     Rochester,     Syracuse       Providence 

N.Y. 


194 


116 


105 


1910  1915   1910  1915   1910  1915   1910  1915   1910  1915 

to   to    to  to     to   to     to   to    to   to 

1914  1919   1914  1919   1914  1919   1914  1919   1914  1919 


Secondly,  the  tuberculosis  death  rate  in  Newport  and  in  the  small 
towns  of  the  state,  while  lower  than  that  for  the  four  large  industrial 
centers,  is  still  high  enough  to  constitute  a  serious  health  problem. 
Even  in  these  relatively  favored  sections  more  than  one  person  in 
every  thousand  dies  every  year  of  tuberculosis  and  conditions  by 
no  means  warrant  the  almost  complete  neglect  of  administrative 
machinery  for  the  control  of  this  disease. 


III.     ADMINISTRATIVE    MACHINERY    FOR    THE    CON- 
TROL   OF   TUBERCULOSIS    IN    RHODE    ISLAND. 

While  tuberculosis  is  a  communicable  disease,  it  is  clear  that  it 
differs  widely  from  the  more  acute  contagia  in  the  relative  import- 
ance of  the  parts  played,  respectively,  by  the  invading  microbe  and 
the  vital  resistance  of  the  human  body.  The  tubercle  bacillus  is  so 
widely  distributed  that  extreme  rigor  in  administrative  control 
would  be  as  ineffective  as  it  would  be  unwise.  Two  measures  of 
control  are,  however,  essential  in  dealing  intelligently  with  this  dis- 
ease,— a  law  requiring  the  reporting  of  all  known  cases  and  a  law 
permitting  the  isolation  of  any  individual  w^ho  is  known  to  be  a  dis- 
seminator of  tubercle  bacilli  and  who  wilfully  and  habitually  refuses 
to  observe  the  simple  precautions  necessary  to  protect  his  neighbors 
from  the  danger  of  infection.  Rhode  Island  has  both  these  laws 
upon  its  statute  books,  although  their  enforcement  leaves  much  to 
be  desired. 

Tuberculosis  was  made  a  reportable  disease  in  the  city  of  Provi- 
dence by  a  rule  of  the  Board  of  Aldermen  in  1905.  In  1909,  how- 
ever, a  state  law  was  passed  requiring  the  reporting  of  this  disease 
directly  to  the  State  Board  of  Health  (Ch.  386).  The  state  law 
also  requ'res  the  reporting  of  tuberculosis,  along  with  other  com- 
municable diseases,  to  the  local  health  officers  throughout  the  state 
(Ch.  110).  In  Providence,  at  least,  it  has  seemed  unwise  to  the 
local  health  authorities  to  require  a  double  reporting  of  tuberculosis 
and,  since  1909,  reports  to  the  city  health  officer  have  been  allowed 
to  lapse. 

Since  the  control  of  tuberculosis  must  be  largely  a  local  matter 
it  would  be  most  unfortunate  if  city  and  town  health  officers  re- 
mained without  knowledge  of  the  existence  of  cases  of  this  disease 
within  their  respective  jurisdictions.     This  was  at  first  an  unfor- 

19 


tunate  effect  of  the  law  of  1909.  Lately,  however,  transcripts  of  all 
reports  of  cases  of  tuberculosis  made  to  the  State  Department  of 
Health  have  been  promptly  forwarded  to  local  health  officers.  So 
long  as  this  is  done,  and  if  the  reporting  law  is  effectively  enforced, 
there  would  seem  to  be  no  insuperable  disadvantages,  and  for  rural 
districts  certain  positive  advantages,  in  a  state  reporting  law. 

The  general  principle  that  reports  should  be  made  to  the  office 
which  is  to  exercise  control  is,  however,  a  sound  one.  In  the  smaller 
towns  direct  control  will  have  to  be  exercised  by  the  state,  if  it  is 
exercised  at  all.  In  Providence  this  is  not  the  case.  Without 
change  in  the  existing  law  it  would  be  feasible  for  the  State  Board  of 
Health  to  make  the  City  Health  Officer  its  deputy  for  the  collection 
of  reports  in  Providence.  This  would  give  the  local  office  the  direct 
contact  with  reporting  which  Dr.  Chapin  feels  to  be  essential  for 
effective  control  and  after  transcription  the  reports  could  be  for- 
warded to  the  State  House.  I  would  strongly  urge  that  the  State 
Board  of  Health  make  an  arrangement  of  this  kind. 

That  the  present  reporting  law  is  not  being  taken  at  all  seriously 
by  the  physicians  of  the  state  is,  however,  clearly  indicated  by  the 
figures  for  reported  cases  presented  in  Table  VI.  These  data, 
courteously  furnished  by  Dr.  B.  U.  Richards,  Secretary  of  the  State 
Board  of  Health,  when  compared  with  the  mortality  returns  in 
Table  II,  show  that  the  reported  case  rate  for  nine  years  averages 
only  1.40  cases  per  1000  population,  as  compared  with  a  death  rate 
for  the  same  period  of  1.66  per  1000.  In  other  words,  for  each  100 
cases  reported  there  were  118  deaths.  An  idea  of  what  may  be  ex- 
pected from  a  reasonably  good  enforcement  of  reporting  laws  may 
be  gained  from  the  data  in  Table  VII,  from  the  Report  of  the  Massa- 
chusetts State  Board  of  Health  for  1915.  The  reporting  even  here 
is  of  course  incomplete;  but  it  is  more  than  twice  as  good  as  that 
attained  in  Rhode  Island.  The  careful  studies  conducted  in  Fram- 
ingham,  Mass.,  by  the  Framingham  Community  Health  and  Tu- 
berculosis Demonstration  indicate  that  as  a  matter  of  fact  the 
ratio  of  existing  cases  in  a  given  community  is  about  9  cases  to  1 
death,  and  the  actual  normal  case  rate  about  10  per  1000  population. 

That  this  estimate  is  applicable  to  Rhode  Island,  is  indicated  by 
the  survey  of  post-influenza  cases  conducted  l)y  the  District  Nursing 
Association  after  the  epidemic  of  1918.  Out  of  1805  persons  vis- 
ited 27,  or  15  per  1000,  were  tuberculous,  and  since  post-influenza 

20 


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21 


Fatal 

ity  Rate. 

Deaths  per 

100 

cases 

148 

.4 

105 

.1 

74 

.9 

54 

.4 

909, 

added   to 

year 

57 

3 

62 

.8 

56 

0 

56 

4 

58 

.4 

TABLE  VII. 

Cases  and  Deaths  from  Pulmonary  Tuberculosis  in  Massachusetts. 

Case  Rate  Death  Rate 

Year                    per  100,000  per  100,000 

1906  100.4  149.1 

1907  143.6  150.6 

1908  183.6  137.4 

1909  244.7  132.7 

1909  (Dec.)      (Case  rate  and  fatality  rate  for  December, 

1909) 

1910  232.6  133  1 

1911  204  1  128.0 

1912  214.2  119  9 

1913  207.6  117.0 

1914  196.2  114.1 

1915  217.0  113.2  52  2 

(Report,  State  Department  of  Health,  Massachusetts,  1915,  p.  613) 


cases  would  probably  show  a  tuberculosis  incidence  somewhat 
higher  than  normal,  the  results  may  be  considered  as  closely  check- 
ing the  Framingham  conclusions.  We  may  assume  that  about 
6000  cases  of  tuberculosis  actually  exist  in  Rhode  Island,  of  which 
about  1000  are  now  reported. 

In  order  to  gain  an  idea  as  to  the  relative  incompleteness  of  the 
reporting  in  various  areas  we  have  prepared  Table  VIII  for  the 
years  1911  to  1919.  There  are  several  points  which  should  be  taken 
into  consideration  in  interpreting  these  figures.  The  death  sta- 
tistics have  all  been  corrected  by  distributing  the  deaths  occurring 
in  tuberculosis  hospitals  and  sanatoria  to  the  cities  and  towns  of 
actual  residence,  but  the  case  rates  have  not  been  corrected  in  this 
manner.  This  factor  would  tend  to  decrease  the  ratio  of  deaths  to 
cases  in  Providence  and  in  the  "rest  of  the  State"  (the  latter  in- 
cluding Cranston  and  Wallum  Lake).  On  the  other  hand  the 
deaths  which  occur  in  general  hospitals  would  tend  to  increase  un- 
duly the  fatality  rates  in  the  larger  cities.  On  the  whole  it  seems 
probable  that  the  data  presented  indicated  particularly  lax  report- 
ing in  Newport  and  in  the  "rest  of  the  State,"  which  is  exactly 
what  we  should  expect  from  the  fact  that  these  areas  are  lacking  in 
organized  clinic  facilities. 


22 


TABLE  VII. 
Incompleteness  of  Reporting  of  Tuberculosis  in  Various  Areas. 

1911-1919 


Average  Number 

Average  Number 

Apparent  Fatality 

Cases  per  year 

Deaths  per  year 

.  Rate. 

Deaths  per 

100  Cases. 

Providence 

412 

466 

113 

Pawtucket 

88 

87 

98 

Woonsocket 

58 

68 

117 

Central  Falls 

40 

39 

97 

Newport 

20 

37 

185 

Rest  of  State 

208 

269 

129 

With  regard  to  the  machinery  available  for  the  control  of  the 
occasional  wilfully  careless  consumptive,  Chapter  110  of  the  General 
Laws  provides  that  cases  of  tuberculosis  shall  be  "suitably  quaran- 
tined" and  the  term  is  defined  as  meaning  "the  isolation  of  the  per- 
son or  persons  having  the  disease  or  distemper,  and  of  such  other 
persons  as  may  by  contact  or  association  with  the  affected  person 
become,  in  the  judgment  of  the  state  board  of  health,  carriers  of  con- 
tagion. The  period  of  time,  the  manner  of  such  isolation  and  the 
method  of  cleansing  and  disinfection  shall  be  in  accordance  with 
the  rules  and  regulations  made  from  time  to  time  by  said  Board." 

The  State  Board  of  Health  appears  to  have  made  no  specific  rules 
and  regulations  under  this  act,  certain  earlier  regulations  having 
been  presumably  superseded  by  a  set  of  "Rules  Governing  Control 
of  Contagious  Diseases,"  issued  in  1919.  The  latter  document  is 
essentially  a  transcript  of  a  report  on  the  control  of  communicable 
diseases  by  a  committee  of  the  American  Public  Health  Association. 
This  report  laid  down  the  general  scientific  principles  underlying 
the  control  of  such  diseases  but  was  not  designed  in  any  sense  to 
serve  the  purpose  of  a  legally  enforceable  draft  of  rules  and  regula- 
tions. I  am  informed  that  the  City  Solicitor  of  Providence  holds  it 
necessary  for  the  State  Board  of  Health  to  make  a  specific  individual 
ruling  in  regard  to  each  particular  case  of  tuberculosis  to  be  isolated 
under  Chapter  110, — a  procedure  which  would  certainly  be  intol- 
erable in  dealing  with  more  acute  disorders  but  which  may  perhaps 
serve  for  the  rare  instances  in  which  forced  isolation  of  tuberculosis 
is    desirable. 

A  third  very  desirable  legal  provision  is  found  in  Chapter  576  of 
the  Public  Laws  which  prohibits  tuberculous  persons  from  handling 
food  products. 

23 


Aside  from  forcible  legal  control  it  is  essential  that  the  public 
authorities  should  offer  facilities  for  the  laboratory  diagnosis  of 
tuberculosis  and  this  is  done  by  the  State  Board  of  Health.  Dr. 
L.  A.  Round,  Director  of  the  Laboratory'  of  the  State  Depart- 
ment of  Health,  has  courteously  furnished  us  with  the  data  pre- 
sented in  Table  IX  in  regard  to  the  scope  and  extent  of  this  work 
for  the  past  six  years. 

TABLE  IX. 
Work  of  the  State  Laboratory  in  the  Diagnosis  of  Tuberculosis. 
Number  of  Speciments  Examined. 
Year  Positive 


1915 

501 

1916 

533 

1917 

493 

1918 

348 

1919 

417 

1920  (to  Sept.  1) 

249 

egative 

Total 

1705 

2266 

1921 

2454 

1967 

2460 

1752 

2100 

1731 

2148 

933 

1182 

Totals  2541  10069  12610 

The  state  law  (Chapter  386)  requires  that  the  State  Board  of 
Health  shall  keep  a  register  of  all  reported  cases  of  tuberculosis  and 
this  is  done.  The  physicians  of  the  state  are  provided  with  report 
bkmks  of  the  form  indicated  below.  A  minor  point  of  friction  could 
be  eliminated  by  combining  this  report  blank  with  the  blank  which 
must  accompany  a  sample  of  sputum  sent  to  the  State  Laboratory. 
At  present  the  physician  must  fill  out  one  form  to  go  with  the  speci- 
men and  later  make  out  the  full  report  blank  below  which  involves 
apparently  unnecessary  duplication. 

Keport  of  a  Case  of  Tuberculosis  to  the  R.  I.  State  Board  of  Health. 

R.  1 19 

Name 

[Married 

Age Se.\« Color <{  Single 

[Widower 


Street City.  . 

Residence  No i  _,      ,  t, 

I  Road Town 


Occupation,  trade,  profession  or  particular  kind  of  work 

General  nature  of  industry,  business  or  establishment  in  which  employed 
Working  in  what  Shop  or  Mill,  etc.,  for  how  long  previous  to  date? 


24 


Form  of  Disease:     Pulmonary,  Laryngeal,  Local  or  General 

How  long  has  patient  had  the  disease? 

Any  exposure  to  another  case? 

Have  there  been  any  other  cases  in  the  same  family? ' 

Have  there  been  any  other  cases  in  the  same  house? 

How  recently? 

Would  you  deem  it  desirable  that  a  member  of  the  District  Nursing  Association 

call  upon  this  patient  to  give  advice  or  render  assistance? 

If  an  infant  is  it  fed  on  cow's  milk? 

If  so,  is  the  name  of  the  milk  dealer  known? 

Reported  by 

M.  D. 

Upon  receipt  of  this  report  additional  blanks  and  stamped  addressed  en- 
velopes will  be  forwarded  for  report  of  any  new  cases. 

The  report  blanks  are  kept  on  file  in  the  State  House,  a  transcript 
being  forwarded  to  the  local  health  officer,  as  indicated  above. 
When  the  physician's  report  specifically  calls  for  the  services  of  a 
public  health  nurse  the  State  Board  notifies  the  district  nursing 
association  of  the  town.  The  form  of  the  question  on  the  report 
blank,  however,  puts  the  responsibility  of  a  definite  appeal  for 
nursing  aid  upon  the  physician;  and  unless  he  makes  such  an  appeal 
no  supervision  is  attempted. 

In  addition  to  the  keeping  of  the  tuberculosis  register  and  the 
provision  of  laboratory  facilities,  the  State  Board  of  Health  dis- 
tributes an  excellent  circular,  "Advice  to  Patients  having  Tubercu- 
losis of  the  Lungs"  and  provides  sputum  cups  and  paper  napkins 
free  of  charge.  This  is  the  sum  and  substance  of  the  part  played  by 
the  State  Board  of  Health  in  the  campaign  against  the  most  preva- 
lent and  most  deadly,  of  all  preventable  diseases. 

Dr.  Richards  and  Dr.  Round,  in  the  Bulletin  of  the  State  Board 
for  February,  1919,  called  special  attention  to  the  danger  of  the  dis- 
semination of  tuberculosis  by  raw  milk  and  urged  the  enactment  of 
legislation  providing  for  the  supervision  of  the  production,  transpor- 
tation and  sale  of  milk.  Dr.  Round  states  that  five  out  of  seven 
samples  of  "Baby's  milk"  collected  in  Providence  contained  tubercle 
bacilli  and  adds,  "What  are  we  doing  about  it?  Nothing!"  Not 
more  than  60  per  cent  of  the  milk  supply  of  Providence  is  at  present 
rendered  safe  by  pasteurization. 

Municipal  health  authorities  appear  to  be  even  less  interested  in 
the  problems  of  tuberculosis.  Outside  of  Providence  our  canvass 
of  the  situation  has  revealed  no  special  health  department  activities 

25 


along  this  line;  and  even  in  Providence  the  official  machinery  for 
dealing  with  tuberculosis  is  extremely  tenuous.  A  vigorous  and 
well  planned  anti-tuberculosis  program  was  initiated  by  the  Provi- 
dence Health  Department  in  1905,  but  when  the  new^  state  report- 
ing law  went  into  force  in  1909  this  program  was  permitted  to  lapse. 
Even  the  municipal  laboratory  diagnosis  was  finally  discontinued,  as 
a  result  of  misguided  parsimony  on  the  part  of  the  civic  authorities. 
Lately,  however,  the  more  cooperative  attitude  of  the  State  Board 
of  Health  has  made  possible  the  very  desirable  resumption  of  local 
activities.  Two  years  ago  a  nurse  was  employed  by  the  city  health 
department  to  prepare  a  card  index  of  known  cases  of  tuberculosis 
in  Providence,  based  on  the  reports  transmitted  by  the  State  Board 
of  Health,  and  on  data  obtained  from  the  District  Nursing  Associa- 
tion and  other  agencies.  Thus  there  is  available  an  up-to-date  local 
register  of  tuberculosis  which  has  grown  from  102  7  frank  cases  and  173 
suspicious  cases  in  August,  1919,  to  1170  frank  cases  and  325  suspi- 
cious cases  in  August,  1920.  Of  the  1170  frank  cases,  1037,  were  of 
pulmonary  tuberculosis  and  133  of  other  forms.  The  laboratory 
diagnosis  of  local  cases  of  tuberculosis  was  also  resumed  in  Febru- 
ary, 1920  (after  the  closing  of  the  city  laboratory  for  a  year);  and 
during  the  ten  months,  December,  1919,  through  September,  1920, 
322  specimens  were  examined  in  the  city  laboratory. 

No  follow-up  work  of  reported  cases  is  attempted,  however,  al- 
though a  visit  is  made  following  each  reported  death  from  tubercu- 
losis. 

Both  the  State  Board  of  Health  and  the  City  Department  of 
Health,  therefore,  practically  limit  their  activities  in  regard  to  tu- 
berculosis to  the  provision  of  laboratory  diagnosis  and  the  keeping 
of  a  register  of  known  cases  of  the  disease.  Such  a  condition  is  by 
no  means  unusual;  for  curiously  enough  the  task  of  combating  tu- 
berculosis has  very  commonly  been  left  to  the  initiative  of  private 
organizations.  Such  organizations  have  striven  earnestly  and  effec- 
tively, in  Rhode  Island  as  elsewhere,  to  meet  the  responsibilities 
which  have  been  placed  upon  them;  and  they  will  always  have  an 
important  function  to  perform  in  supplementing  the  work  of  public 
agencies.  A  complete  program  of  tuberculosis  control  must,  how- 
ever, center  about  the  inspiring  leadership  of  the  constituted  health 
authorities;  and  it  is  more  than  time  that  legislatures  and  municipal 
councils  should  be  awakened  to  their  responsibility  in  regard  to 
this  grave  health  problem. 

26 


For  the  effective  control  of  tuberculosis  in  Rhode  Island  I  believe 
it  to  be,  first  of  all,  essential  that  the  State  Board  of  Health  should 
promulgate  hew  and  specific  regulations  in  regard  to  the  control 
of  this  disease  which  shall  ensure  the  adequate  supervision  of  each 
reported  case,  a  supervision  which  at  present  is  practically  non- 
existent. The  proper  policy  is,  I  believe,  embodied  in  the  tuber- 
culosis law  of  New  York  State.  This  law  requires  the  reporting  of 
every  case  of  tuberculosis  within  twenty-four  hours.  It  makes  it 
obligatory  upon  the  local  health  officer  to  call  this  provision  to  the 
attention  of  any  physician  signing  a  death  certificate  for  tuberculo- 
sis who  has  not  previously  reported  the  disease,  and  in  case  of  re- 
peated violations  the  health  officer  sliall  report  such  violations  to 
the  local  health  authorities  who  shall  cause  such  steps  to  be  taken 
as  may  be  necessary  to  enforce  the  penalty  for  such  violation. 
Whenever  a  case  of  tuberuclosis  is  reported,  the  local  health  officer 
must  transmit  to  the  physician  "a  printed  statement  and  report  in 
a  form  approved  by  the  state  commissioner  of  health,  naming  such 
procedure  and  precautions  as  in  the  opinion  of  said  commisisoner 
are  necessary  or  desirable  to  be  taken  on  the  premises  of  a  tuber- 
culosis patient."  Upon  receipt  of  this  statement  the  physician 
must  s'gn  and  date  the  report,  agree  to  carry  out  such  precautions  or 
if  unwilling  to  do  so  he  must  so  state  upon  the  report,  whenthe  duties 
prescribed  devolve  upon  the  local  health  ofificer.  The  health  officer 
has  the  authority  to  cause  all  reported  cases  of  tuberculosis  in  his 
jurisdiction  to  be  visited  from  time  to  time  by  a  public  hea'th  nurse. 
Whenever  a  complaint  shall  be  made  by  a  physician  to  a  health 
officer  that  a  patient  suffering  from  tuberculosis  is  unable  or  unwill- 
ing to  conduct  himself  and  to  live  in  such  a  manner  as  not  to  expose 
members  of  his  family  or  household  or  other  persons  to  infection, 
the  health  officer  should  investigate  the  circumstances  and,  if  he 
finds  ground  for  so  doing,  he  shall  lodge  a  complaint  with  the  magis- 
trate upon  which  the  offending  patient  can  be  brought  before  the 
magistrate  and  committed  to  a  county  hospital  for  tuberculosis  or 
to  any  state  hospital  or  institution  which  cares  for  this  disease. 

The  same  principles  are  embodied  in  the  Sanitary  Code  of  the 
State  of  Connecticut,  Regulations  35  and  36  of  which  read  as  follows: 

Regulation  35.     Method  of  control  of  tuberculosis. 

"When  a  licensed  physician  or  hospital  superintendent  reports  a 
case  of  tuberculosis  and  agrees  to  assume  the  responsibility  for  the 
proper  instruction  of  the  patient  and  the  taking  of  measures  neces- 

27 


sary  for  the  protection  of  others,  the  health  officer  need  not  take 
action  other  than  prescribed  by  Chapter  79,  PubHc  Acts,  1909. 

"Every  physician  thus  assuming  the  control  of  a  case  of  tubercu- 
losis shall  repori  to  the  local  health  officer  on  or  before  the  first 
day  of  each  month,  stating  whether  or  not  such  case  is  still  under 
his  care,  and  if  such  report  is  not  made,  the  health  officer  shall  in- 
vestigate and  take  such  measures  as  he  deems  necessary  for  the 
protection  of  public  health. 

"When  a  physician  or  hospital  superintendent  declines  to  assume 
such  responsibility,  it  shall  be  the  duty  of  the  health  officer  to  supply 
the  afflicted  person  with  printed  instructions  and  take  such  other 
action  as  may  be  necessary  and  proper  for  the  protection  of  public 
health." 

Regulation  36.  Control  of  refractory  persons  affected  with 
tuberculosis. 

"When  it  comes  to  the  attention  of  a  health  officer  that  a  person 
is  affected  with  tuberculosis  and  is  a  menace  to  the  public  health  or 
is  liable  to  jeopardize  the  health  of  any  person  or  persons  in  or  on 
the  premises  occupied  or  frequented  by  the  afTected  person,  he  shall 
immediately  investigate  and  take  proper  measures  to  prevent  the 
spread  of  such  disease  for  the  protection  of  public  health,  and  if 
necessary  may  cause  the  removal  of  such  person  to  an  isolation  hos- 
pital or  other  proper  place,  there  to  be  received  and  kept  until  he 
shall  no  longer  be  a  menace  to  the  public  health." 

It  would  seem  that  under  Section  13  of  Chapter  110  of  the  Gen- 
eral Laws  the  State  Board  of  Health  of  Rhode  Island  has  ample 
powers  to  formulate  regulations  along  essentially  similar  lines  to 
those  laid  down  in  the  New  York  and  Connecticut  law. 

Outside  of  Providence  it  might  be  necessary  to  make  special  pro- 
vision for  the  care  of  the  few  refractory  cases  which  require  forcible 
detention.  In  Providence  the  City  Hospital  could  be  used  for  this 
purpose. 

Ordinances  requiring  the  pasteurization  of  all  milk  not  of  certified 
grade  are  eminently  desirable;  but  such  ordinances  are  preferably 
issued  by  local  authorities.  I  would  recommend  that  an  earnest 
elifort  be  made  to  secure  such  ordinances  in  Providence,  Pawtucket, 
Woonsocket,  and  other  large  communities.  Newport  already  has 
an  ordinance  of  this  kind. 

Even  more  important  than  legislation,  is  the  provision  of  a  proper 
expert  personnel  for  dealing  with  the  broader  tuberculosis  prob- 

28 


lems  of  the  state.  The  whole  campaign,  at  least  in  that  part  of  the 
state  outside, of  the  city  of  Providence,  should  be  planned  and  di- 
rected by  a  single  competent  leader  who  can,  month  by  month,  watch 
its  progress,  fill  in  gaps  as  they  are  manifest  and  recommend  to  the 
State  Board  of  Health  such  steps  as  may  be  necessary  for  obtaining 
from  time  to  time  a  more  effective  control  of  this  disease.  Such  a 
leader  should  be  a  physician  trained  in  the  diagnosis  of  tuberculosis, 
for  this  branch  of  medicine  is  a  complex  and  dif^cult  specialty,  al- 
most unrepresented  in  Rhode  Island  outside  of  the  city  of  Provi- 
dence except  by  the  staff  of  the  State  Hospital  at  Wallum  Lake. 
He  should  also,  if  possible,  have  had  training  and  experience  in  pub- 
lic health  work.  A  Director  of  a  Division  of  Tuberculosis  under 
the  State  Board  of  Health,  if  properly  qualified,  could  not  only  plan 
the  general  anti-tuberculosis  campaign  for  the  state  as  a  whole  but 
could  also  supervise  existing  clinics,  organize  and,  where  necessary, 
serve  new  clinics,  furnish  itinerant  clinic  service  for  the  rural  dis- 
tricts and  act  as  a  consultant  to  assist  private  physicians  in  the 
diagnosis  of  respiratory  disorders.  The  appointment  of  such  a 
Director  is  perhaps  the  most  important  single  step  to  be  taken  in 
the  development  of  anti-tuberculosis  work  in  Rhode  Island. 

It  might  be  well,  as  suggested  above,  for  such  a  State  Director  of 
Tuberculosis  work  to  devote  his  energies  chiefiy  to  the  portion  of 
the  state  outside  the  city  of  Providence.  Providence  is  a  com- 
munity of  sufficient  size  to  occupy  the  full  service  of  a  specialist  of 
this  type.  Clinic  facilities  and  nursing  service  are  more  ful  y  de- 
veloped in  Providence  than  elsewhere  but  they  are  imperfectly  co- 
ordinated and  experience  has  shown  that  no  agency  short  of  that 
which  represents  the  community  as  a  whole  can  hope  to  effect  har- 
mony between  conflicting  interests.  The  City  Department  of 
Health  should,  therefore,  also  be  provided  with  a  Division  of  Tu- 
berculosis under  a  competent  medical  specialist,  whose  duty  should 
be  to  see  that  all  cases  of  tuberculosis  on  the  register  are  so  cared  for 
as  not  to  be  a  menace  to  others  and  that  each  case  has  every  pos- 
sible opportunity  to  receive  the  medical  and  nursing  care  or  sana- 
torium treatment  necessary  for  his  own  welfare.  His  powers  should 
of  course  be  exercised  only  where  no  private  physician  has  under- 
taken or  will  undertake  to  assume  the  responsibility  for  the  conduct 
of  the  case. 

Si  Arthur  Newsholme  has  well  said  that  when  "the  medical 
officer  of  health  or  the  tuberculosis  officer  takes  little,  if  any,  useful 

29 


action  after  notifications  have  been  received,  the  practitioner  has  an 
excuse  for  not  notifying  subsequent  cases.  He  can  argue  with  some 
cogency  that  notification  has  no  value  per  se;  its  utility  depends  on 
the  action  which  follows  on  notification.  Unless  useful  action  fol- 
lows on  notification,  default  in  notification  has  little  practical  im- 
portance." 

The  principles  which  should  underly  the  official  control  of  tuber- 
culosis may  be  stated  very  simply,  although  the  application  is  by 
no  means  easy  of  realization.  Every  case  of  tuberculosis,  for  which 
a  physician  does  not  assume  direct  responsibility,  should  be  fol- 
lowed up  to  see  (a)  that  the  exposure  of  other  persons  to  infection  is 
minimized,  and  (b)  that  the  individual  affected  is  brought  in  con- 
tact with  facilities  for  medical,  nursing  and  hospital  treatment  and 
given  the  fullest  opportunity  to  avail  himself  of  the  curative  pos- 
sibilities which  they  ofTei.  In  order  that  machinery  may  be  built 
up  for  these  ends  it  is  essential  that  an  official  director  of  anti- 
tuberculosis work  in  the  city  of  Providence  and  another  to  serve  the 
remainder  of  the  state  should  be  appointed  under  the  auspices, 
respectively,  of  the  city  and  state  departments  of  health. 


IV.     CLINIC  SERVICE  FOR  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  TUBERCULOSIS   IN   RHODE   ISLAND. 

The  tuberculosis  clinic  serves  a  double  purpose  as  an  instrument, 
on  the  one  hand  for  the  early  diagnosis  of  the  disease,  and  on  the 
other  for  the  systematic  treatment  of  such  known  cases  as  may 
properly  be  cared  for  outside  the  sanatorium.  In  view  of  its  im- 
portance as  a  diagnostic  agent  the  clinic  deserves  first  place  in  a  re- 
view of  available  machinery  for  the  control  of  tuberculosis. 

In  the  city  of  Providence  there  are  at  present  eight  different  tu- 
berculosis clinics  each  week,  four  at  the  Rhode  Island  Hospital  (one 
for  children),  two  (one  opened  very  lecently)  at  the  City  Hospital 
and  one  each  at  Lyra  Brown  Nickerson  House  and  at  Federal  Hill, 
House  (both  the  latter  being  under  the  direction  of  the  medical 
staff  of  the  City  Hospital).  Outside  of  Providence  five  clinics  are 
held  each  week,  two  in  Pawtucket,  and  one  each  in  Woonsocket, 
Riverpoint  and  East  Providence. 

The  four  clinics  directed  by  the  Rhode  Island  Hospital  are  op- 
erated under  particularly  advantageous  circumstances.     The  Dis- 

30 


pensary  Building  at  the  City  Hospital  plant  itself  and  the  two  settle- 
ment houses  (Lyra  Brown  Nickerson  and  Federal  Hill),  where  these 
clinics  meet,  are  convenient  and  attractive.  Furthermore  Dr. 
D.  L.  Richardson,  superintendent  of  the  City  Hospital,  is  keenly 
interested  in  the  development  of  his  tuberculosis  clinics  and  pur- 
poses in  the  future  to  have  a  member  of  his  full-time  stafT  in  attend- 
ance at  each  clinic  to  ensure  continuity  and  harmony  of  service. 
This  is  the  greatest  need  in  clinic  service  at  the  present  time,  in 
Rhode  Island,  as  everywhere  else.  It  is  hard  to  say  too  much  in 
praise  of  the  busy  physicians  who  in  the  past  have  given  so  gener- 
ously of  their  time  and  energy  in  clinic  service;  but  it  is  unfair  to 
demand,  and  unreasonable  to  expect,  that  unpaid  assistance  can 
ever  fulfill  the  highest  ideals  of  clinic  service.  The  nursing  or- 
ganization of  the  Providence  clinics  on  the  other  hand  is  admirable, 
all  of  them  being  served  by  the  tuberculosis  nurses  of  the  District 
Nursing  Association.  Adequate  clerical  service  is  supplied  by  the 
hospitals  and  settlement  houses  where  the  clinics  are  held. 

The  volume  of  work  accomplished  by  these  clinics  is  indicated 
in  Table  X  below.  It  is  apparent  that  the  City  Hospital  clinics  are 
all  growing  rapidly,  while  the  Rhode  Island  Hospital  clinics  suffered  a 
material  decline  in  numbers  during  the  first  half  of  the  present  year. 


TABLE  X. 

Volume  of  Work  Done  bv  Providence  Clinics. 

Period  Clinics  Number  of  Number  of  visits  by  patients. 

clinics  held     Old  patients     New  patients     Total 


R.  I.  Hospital 

141 

915 

341 

1256 

(3  clinics  for  adults) 

"     children's  clinic 

34 

148 

73 

221 

1918     City  Hospital 

50 

237 

120 

357 

Nickerson  House 

39 

119 

48 

167 

Total  for  year 

264 

151 

1419 
1025 

582 
365 

2001 

R.  I.  Hospital 

1390 

(3  clinics  for  adultsj 

1919         "     children's  clinic 

40 

50 

23 

73 

City  Hospital 

50 

441 

197 

638 

Nickerson  House 

48 

176 

94 

270 

Federal  Hill  House 

16 

88 

50 

138 

Total  for  year 

305 

1780 

729 

2509 

31 


R.  I.  Hospital 

75 

327 

123 

450 

Jan. 

(3  clinics  for  adu 

;lts) 

to 

"     children's  clinic 

22 

91 

31 

122 

June, 

City  Hospital 

25 

309 

105 

414 

1920 

Xickerson  House 

24 

135 

62 

197 

Federal  Hill  House 

23 

131 

60 

191 

Total  for  six  months  169  993  381  1374 

Outside  of  Providence,  there  are  three  well-estabhshed  chnics,  at 
Pawtucket,  Woonsocket  and  Riverpoint,  and  a  new  one  just  opened 
at  East  Providence  which  received  twenty-two  visits  from  eighteen 
patients  during  the  month  of  September.  Tuberculosis  cases  may 
be  cared  for  in  an  emergency  at  the  Newport  Hospital  but  there  is 
no  regularly  organized  clinic. 

The  Pawtucket  clinics  are  held  twice  a  week  at  the  Memorial 
Hospital  in  that  city  and  they  serve  Central  Falls  as  well  as  Paw- 
tucket. During  the  four  months  previous  to  my  visit  (April-July, 
1920),  thirty-two  clinics  had  been  held  and  eighty-nine  new  patients 
and  seventy  old  patients  had  received  treatment. 

The  clinic  at  Riverpoint  is  held  every  Saturday  afternoon  and 
serves  the  Pawtuxet  Valley  district  in  the  towns  of  Coventry  and 
West  Warwick.  It  meets  in  a  commodious  and  attractive  Health 
Center  building,  and  is  fortunate  in  the  keen  interest  of  prominent 
local  physicians,  and  in  the  service  of  an  unusually  able  and  devoted 
nurse.  During  the  twelve  months  from  September,  1919,  to  Au- 
gust, 1920,  fifty-three  clinics  were  held,  with  fifty-three  new  pa- 
tients and  one  hundred  and  eighty-seven  old  patients. 

The  clinic  at  Woonsocket  has  operated  under  considerable  diffi- 
culties. It  is  maintained  chiefly  by  the  earnest  efforts  of  the  dis- 
trict nursing  association.  The  local  medical  society  appoints  six 
different  physicians  during  the  year  to  serve  for  two  months  apiece, 
an  arrangement  which  does  not  make  either  for  continuity  of  policy 
or  skilled  specialist  service.  The  clinic  is  held  once  a  week  and 
during  the  eleven  months,  October,  1919,  to  August,  1920,  seventy 
new  patients  and  seventy-three  old  patients  received  treatment. 

Some  conception  of  the  quantitative  adequacy  of  clinic  service 
may  be  gained  from  Table  XI. 

32 


TABLE  XI. 

Amount  of  Clinic  Service  in  Various  Areas. 

Clinic  Visits  per  month  Visits  per  month  per 

100,000  population 


o 

Eh 

"3 

(2 

o 

Providence 

Rhode  Island  Hospital  (adults)  75 

"    (Children)  20 

►  226 

63 

237,595 

91 

26 

City  Hospital                                 66 

Federal  Hill                                    32 

Lyra  Brown  Nickerson               33 

Pawtucket  and  Central  Falls        40 

22 

88,422 

45 

25 

Woonsocket                                      13 

6 

43,496 

30 

14 

Pawtuxet  Valley  (Coventry  and 

West  Warwick)                             20 

4 

21,131 

95 

19 

East  Providence                                22 

18 

21,793 

101 

83 

It  is  evident  that  from  the  standpoint  of  new  patients  per  unit  of 
population  both  Providence  and  Pawtucket  are  fairly  well  served. 
(The  figures  for  East  Providence  are  of  course  abnormal  since  they 
refer  to  the  first  month  of  operation  of  this  clinic.)  The  ratio  of  new 
patients  admitted  to  all  tuberculosis  clinics  in  New  York  City  for 
the  twelve  months,  October,  1919  to  September,  1920,  was  29  per 
month  per  100,000  population.  On  the  basis  of  total  visits  per 
month  per  100,000  population,  however,  both  Pawtucket  and  Woon- 
socket show  up  very  badly.  Even  in  Providence  and  at  Riverpoint 
the  ratios  of  91  and  95  visits  per  month  per  100,000  population, 
while  it  compares  favorably  with  the  ratio  existing  in  many  com- 
munities (the  corresponding  figure  for  New  Haven  is  97),  falls  far 
short  of  the  standard  set  in  New  York  City  where  the  admirable 
system  of  clinic  statistics  shows  an  average  of  173  visits  per  month 
per  100,000  population  for  the  twelve  months,  October,  1919  to 
September,  1920.  Evidently  the  existing  Rhode  Island  clinics  are 
getting  the  patients,  but  are  failing  to  hold  them;  and  nearly  a  third 
of  the  state  population,  outside  the  cities  listed  in  the  table,  is  en- 
tirely without  local  tuberculosis  clinic  facilities. 

The  measurement  of  the  quality,  as  distinguished  from  the 
quantity,  of  clinic  work  is  an  exceedingly  difficult  task.  In  New 
York  the  Association  of  Tuberculosis  clinics  requires  all  its  members 
to  prepare  a  monthly  report  which  includes  a  classification  of  dis- 

33 


charged  cases  according  to  duration  of  treatment,  reason  for  dis- 
charge and  condition  at  time  of  discharge.  No  such  data  are  pre- 
pared by  the  Providence  cHnics.  The  ratio  of  new  to  old  cases 
treated  gives  us  a  rough  measure,  however,  of  the  efficiency 
with  which  the  cHnic  holds  its  patients. 

Variations  in  the  type  of  patients  treated  will  of  course  affect 
this  ratio  and  it  is  evident  that  even  a  single  visit  may  be  wholly 
adequate  if  it  leads  to  prompt  admission  to  a  sanatorium.  On  the 
whole,  however,  in  a  large  clinic  this  ratio  varies  pretty  closely  with 
efficiency  of  service  and  furnishes  one  of  the  objective  criteria,  so 
much  to  be  desired  in  measuring  the  quality  of  public  health  agen- 
cies. In  New  Haven,  for  example,  the  clinic  at  the  New  Haven 
Dispensary  shows  a  ratio  of  3.3  visits  per  new  patient  while  the  City 
Clinic,  which  has  been  more  or  less  disorganized  by  unavoidable 
changes  in  medical  personnel,  shows  a  ratio  of  1.7  visits  per  new 
.patient.  The  well  organized  clinics  of  New  York  City  show  a  ratio 
for  the  past  twelve  months  of  6.0  visits  for  each  new  patient  ad- 
mitted.    On  the  basis  of  this  ratio,  it  appears  from  Table  XH  that 


TABLE  XII. 

Frequency  of  Attendance  on  the  Part  of  the  Individual  Patient. 
Clinic  Ratio  of  Total  Visits  to  New  Patients* 

Providence 

Rhode  Island  Hospital  (adults)  3  .7 

(children)  3.9 

City  Hospital  3  .9 

Federal  Hill  3  .2 

Lyra  Brown  Nickerson  3  .2 

Pawtucket  and  Central  Falls  1  .8 

Woonsocket  2,0 

Pawtuxet  Valley  4.5 

the  Riverpoint  (Pawtuxet  Valley)  clinic  is  attaining  good  results, 
the  City  Hospital  and  Rhode  Island  clinics  are  doing  fairly  well, 
the  Federal  Hill  and  Lyra  Brown  Nickerson  clinics  less  well  and  the 
Pawtucket  and  Woonsocket  clinics  very  poorly.  It  is  probable 
that  the  failure  to  hold  patients  in  the  last  two  instances  is  chiefly 
due  to  the  lack  of  continuous  medical  service  by  specialists;  but  the 
nursing  service  in  these  two  cities  is  also  perhaps  not  up  to  the 

*Note  that  this  ratio  is  higher  than  the  ratio  of  visits  par  patient   in   Table    XIII,   since  it  is 
computed  from  the  total  visits  and  the  new  patients. 

34 


standard  set  in  Providence  and  at  Riverpoint.  Conditions  at  the 
Pawtucket  clinic  are  being  materially  improved  through  the  active 
interest  of  Dr.  James  Wheaton. 

In  order  to  gain  a  somewhat  clearer  conception  of  the  actual  na- 
ture of  the  clinic  work  Mr.  Chandler  analyzed  the  individual  rec- 
ords of  209  patients  from  the  Rhode  Island  clinic  and  of  172  pa- 
tients from  the  City  Hospital  clinic,  the  cases  being  taken  at  ran- 
dom, among  those  admitted  prior  to  July  1,  1919,  so  that  all  should 
have  been  under  care  for  at  least  one  year.  The  results  are  pre- 
sented in  Table  XIII.  Aside  from  the  fact  that  a  larger  propor- 
tion of  cases  are  recorded  as  definitely  non-tuberculous  at  the  City 
Hospital  the  results  at  the  two  clinics  are  fairly  comparable.  The 
Rhode  Island  Hospital  clinic  is  somewhat  more  successful  in  secur- 
ing'institutional  treatment,  although  both  records  in  this  respect 
are  very  good.  Excluding  cases  found  to  be  non-tuberculous,  the 
Rhode  Island  Hospital  placed  36  per  cent  of  its  cases  in  hospitals 
or  sanatoria,  the  City  Hospital,  30  per  cent.  Exactly  the  same  pro- 
portion of  cases  in  each  instance  was  kept  under  observation  with 
deferred  diagnosis  and  11  per  cent  of  the  cases  were  kept  under 
observation  with  a  definite  diagnosis  at  the  Rhode  Island  against 
18  per  cent  at  the  City  Hospital  (percentage  computed  after  ex- 
cluding cases  definitely  pronounced  non-tuberculous).  The  small 
proportion  of  cases  reported  as  lost  is,  in  both  cases,  most  gratifying. 

TABLE  XIII. 
Analysis  of  a  Random  Series  of  Clinic  Cases. 


Rhode 

Island  Hospital 

City  Hospital 

Visits 

Visits 

Classification 

Per 

per 

Per 

per 

No. 

Cent 

patient 

No. 

Cent 

patient 

Found  non-tuberculous 

52 

25 

2.3 

80 

46 

2.1 

Admitted  to  sanatorium  or  hos- 

pital 

57 

27 

2.8 

28 

16 

2.8 

Kept  under  observation. 

Tu- 

berculous. 

17 

8 

3.1 

17 

10 

3  4 

Kept  under  observation. 

Di- 

agnosis  deferred. 

56 

27 

2.3 

29 

16 

2  5 

Moved  from  city 

9 

4 

3.9 

3 

2 

2.3 

Lost 

8 

4 

1.0 

4 

2 

1.5 

Dead 

10 

5 

1.3 

9 

5 

3.4 

Discharged  to  physicians 

2 

1 

2.5 

Total  209       100  2.5  172  2.5 

35 


It  will  be  noted  that  the  number  of  visits  to  the  cHnic  per  patient 
is  over  three  for  the  cases  definitely  diagnosed  as  tuberculous  and 
kept  under  observation  at  home,  just  under  three  for  the  group  finally 
placed  in  institutions,  2.3  to  2.5  for  the  group  kept  under  observa- 
tion with  deferred  diagnosis  and  2.1  to  2.3  for  the  patients  definitely 
pronounced  non-tuberculous. 

The  results  of  this  analysis  indicate  that  our  comparison  of  the 
ratio  of  clinic  visits  to  new  patients  in  New  York  and  in  Rhode 
Island  is  not  seriously  vitiated  by  differences  between  the  type  of 
patients  handled.  The  proportion  of  cases  found  non-tuberculous 
was  25  per  cent  at  the  Rhode  Island  and  46  per  cent  at  the  City 
Hospital,  against  40  per  cent  for  the  New  York  clinics,  in  1919. 
If  anything  the  Rhode  Island  Hospital  clinic  should  require  a  higher 
average  of  visits  per  case.  The  disadvantages  under  which  'the 
Rhode  Island  Hospital  clinic  would  appear  to  labor  on  the  face  of 
these  figures  is  however  in  great  measure  counterbalanced  by  the 
very  large  group  of  cases  with  deferred  diagnosis  (27  per  cent). 

There  is  a  real  difference,  on  the  other  hand,  between  the  Provi- 
dence and  New  York  clinics  in  regard  to  the  utilization  of  sana- 
torium treatment.  The  Rhode  Island  clinic  shows  27  per  cent  of 
its  cases  admitted  to  a  sanatorium  or  discharged  to  other  medical 
care,  and  the  City  Hospital,  17  per  cent;  while  the  corresponding 
figure  for  the  New  York  City  clinics  in  1919  was  only  9  per  cent. 
This  contrast  may  help  to  account  for  the  lower  ratio  of  visits  in 
Providence;  but  its  influence  cannot  obviously  be  important,  since 
Table  XIII  shows  that  the  visits  per  patient  in  the  Providence  clinics 
were  actually  higher  in  the  case  of  the  cases  admitted  to  sanatoria 
than  for  the  general  average  of  all  patients  treated. 

Somewhat  in  contrast  to  the  Providence  figures  are  the  data  ob- 
tained from  a  study  of  70  consecutive  cases  admitted  to  the  Woon- 
socket  clinic  which  showed  23  cases  {33  per  cent)  pronounced  non- 
tuberculous  and  only  8  (11  per  cent)  admitted  to  hospitals  or  sana- 
toria.    The  average  visits  per  patient  in  this  series  was  only  1.7. 

The  conclusions  which  may  be  drawn  from  a  review  of  the  tuber- 
culosis clinic  situation  in  Rhode  Island  may  be  summarized  as  fol- 
lows: 

In  Providence  the  clinics  are  fairly  adequate  in  the  amount  of 
service  rendered  and  are  on  the  whole  operating  with  success. 
Through  the  efforts  of  the  District  Nursing  Association  it  is  possible 
to  keep  in  some  sort  of  contact  with  90  per  cent  of  all  patients  who 

36 


once  visit  a  clinic  and  the  fact  that,  of  all  patients  not  definitely  pro- 
nounced non-tuberculous  one-third  are  actually  admitted  to  hos- 
pitals or  sanatoria  is  most  gratifying,  although  the  ratio  of  visits 
per  patient  is  as  usual  regrettably  low.  An  obvious  deficiency  is  to 
be  found  in  the  inadequacy  of  the  system  of  records  in  use.  The 
records  kept  by  the  nurses  are  excellent  so  far  as  they  go,  but  it  is 
most  important,  in  order  that  the  efficiency  of  the  clinics  may  be 
properly  appraised,  to  institute  a  system  of  medical  records  which 
shall  show  clearly,  at  monthly  intervals,  how  many  patients  have 
been  admitted  and  at  what  stage  of  the  disease  process,  how  many 
have  been  discharged,  for  what  reasons,  and  in  what  condition,  how 
many  patients  remain  under  care  and  to  what  grades  of  disease  they 
belong;  and  which  shall  make  it  possible  to  compute  the  true  ratio 
of  visits  per  patient  and  the  average  length  of  time  for  which  various 
classes  of  patients  remain  under  care. 

As  a  general  principle  it  seems  clear  that  the  fullest  development 
of  clinic  service  in  the  future  will  demand  the  payment  of  the  physi- 
cians who  attend  the  clinics.  The  City  Hospital  is  fortunate  in 
having  a  full-time  staff  which  can  be  utilized  so  as  to  secure  adequate 
medical  supervision  of  its  clinic  service,  and  the  extension  of  the 
plan  of  paid  medical  service  must  be  given  serious  consideration  in 
the  future  for  all  clinics  of  this  type. 

Finally  it  must  be  recognized  that  there  is  a  certain  proportion 
of  dispensary  cases  of  tuberculosis  in  which  domiciliary  visits  by  a 
physician  are  essential  to  adequate  control  of  the  disease.  Such 
domiciliary  visits  should  not  be  made  on  an  eleemosynary  basis 
but  as  a  part  of  the  duty  which  the  community  owes  to  its  citizens 
in  the  protection  of  the  public  health.  The  working  out  of  detailed 
plans  for  the  attainment  of  these  three  desiderata,  the  standardiza- 
tion and  extension  of  clinic  records,  the  reorganization  of  clinic 
medical  service  on  a  proper  financial  basis,  and  the  provision  of  oc- 
casional medical  service  for  domiciliary  cases  is  beyond  the  scope  of 
the  present  survey.  They  should  form  the  first  duties  of  the  Di- 
rector of  Tuberculosis,  whose  appointment  as  an  officer  of  the  muni- 
cipal health  department  has  been  recommended  above. 

Outside  the  city  of  Providence,  conditions  in  regard  to  clinic  fa- 
cilities are  far  less  satisfactory.  The  Pawtuxet  Valley  is  admirably 
served  by  the  Riverpoint  clinic.  The  Pawtucket  and  Woonsocket 
clinics  on  the  other  hand  are  by  no  means  on  a  satisfactory  basis. 
The  attendance  per  100,000  population  has  been  low  and  the  ratio 

37 


of  two  visits  or  less  per  new  patient  indicates  a  waste  of  resources 
and  a  failure  to  serve  effectively  even  the  small  clientele  which  is 
reached.  Outside  of  the  cities  of  Providence,  Pawtucket,  and 
Woonsocket  and  the  towns  of  West  Warwick  and  Coventry  there 
is  no  regular  clinic  service  at  all.  The  entire  southern  half  of  the 
state,  the  northwestern  quarter  of  the  state  and  the  Newport 
region  are  without  clinical  facilities,  including  nearly  one  third  of 
the  population  of  Rhode  Island. 

The  first  duty  of  the  Director  of  Tuberculosis  of  the  State  Board 
of  Health  should  be  to  stimulate  the  development  of  the  Pawtucket 
and  Woonsocket  clinics  on  the  most  effective  basis,  to  secure  the 
establishment  of  new  clinics  in  Newport  and  perhaps  in  Cranston, 
Warwick  and  Bristol,  and  to  provide  in  some  way  for  occasional 
clinic  service  in  the  smaller  rural  communities.  The  latter  object 
might  be  attained  through  visits  to  be  made  by  the  Director  to 
rural  communities  where  prospective  patients  had  been  located 
through  the  activity  of  visiting  or  industrial  nurses;  and  in  any  of 
the  larger  centers  where  specialists  equipped  to  diagnose  tuberculo- 
sis are  not  available,  the  State  Director  might  well  arrange  to  con- 
duct a  weekly  clinic  in  person.  The  well  equipped  staff  of  the 
State  Sanatorium  at  Wallum  Lake  could  well  be  called  upon  to 
assist  in  this  work. 

Finally,  a  word  should  be  said  in  regard  to  the  importance  of  de- 
veloping the  general  medical  service,  available  for  the  community 
at  large,  to  the  highest  possible  level  in  respect  to  the  problem  of 
tuberculosis.  The  diagnosis  of  this  disease  is  a  task  of  exceeding 
difficulty  and  for  its  successful  performance  requires  a  detailed 
knowledge  and  a  special  experience  which  the  average  general  prac- 
titioner cannot  be  expected  to  possess.  The  great  value  of  an  ex- 
pert consultation  service  in  the  diagnosis  of  tuberculosis  has  been 
amply  demonstrated  at  Framingham  and  elsewhere ;  and  Dr.  Elliott 
Washburn,  Executive  Secretary  of  the  Providence  Tuberculosis 
League,  has  just  inaugurated  a  consultation  service  of  this  kind  for 
physicians  in  the  city  of  Providence.  This  is  a  most  admirable 
step  and  the  consultation  service,  as  continued  and  extended,  should 
prove  one  of  the  most  valuable  instruments  in  the  anti-tuberculosis 
campaign.  A  very  useful  function  of  the  state  director  of  tubercu- 
losis, whose  appointment  is  recommended  in  this  report,  would  be 
to  offer  such  a  consultation  service  to  physicians  of  the  state  outside 
of  the  city  of  Providence. 

38 


V.     PROVISION     FOR     HOSPITAL     AND     SANATORIUM 
CARE  OF  TUBERCULOSIS   IN   RHODE   ISLAND. 

Provision  for  the  hospital  and  sanatorium  treatment  of  pulmonary 
tuberculosis  in  Rhode  Island  is  made  by  the  following  institutions: 

A.  State  Hospital  and  Sanatorium  at  Wallum  Lake.  Total  of 
363  beds  (sanatorium  cases,  170  beds,  advanced  cases,  153  beds, 
children,  40  beds). 

B.  Providence  City  Hospital,  60  beds  (for  advanced  cases). 

C.  St.  Joseph's  Hospital  Annex,  Hillsgrove,  70  beds  (for  ad- 
vanced cases). 

D.  Tuberculosis  wards,  State  Almshouse  Hospital,  Howard 
(46  beds). 

There  are  also  a  certain  number  of  cases  of  tuberculosis  cared 
for  in  the  State  Hospital  for  Mental  Diseases  at  Howard,  19  in  num- 
ber on  July  1,  1920. 

In  addition  to  the  institutions  designed  for  the  care  of  active 
cases  of  pulmonary  tuberculosis,  there  is  a  Preventorium  at  Hoxsie, 
conducted  by  the  Providence  Tuberculosis  League  and  a  hospital 
for  bone  and  joint  cases  (Crawford  Allen  Branch  of  the  Rhode 
Island  Hospital),  at  East  Greenwich.  The  Preventorium  has  win- 
ter accommodations  for  about  40  children  and  in  summer  can  re- 
ceive about  50.  During  the  year  ending  October  1,  1920,  153  chil- 
dren were  given  9359  days'  care  in  this  institution;  while  in  addi- 
tion convalescent  and  summer  outing  provision  was  made  for  618 
women  and  children  (7845  days'  care). 

The  Crawford  Allen  Branch  has  45  beds  and  is  open  only  in  the 
summer  season,  the  patients  returning  to  their  homes  or  to  general 
hospitals  for  the  winter. 

Returning  to  the  institutions  designed  primarily  for  the  institu- 
tional care  of  active  cases  of  tuberculosis  we  find  provided  a  total 
of  approximately  540  beds,  170  for  early  cases,  283  for  advanced 
cases,  46  for  either  type  (at  the  State  Hospital)  and  40  for  children 
(at  Wallum  Lake).  The  total  provision  amounts  to  1  bed  for  every 
1100  population  or  1  bed  for  every  1.6  annual  deaths  from  tuber- 
culosis. On  the  theoretical  basis  which  calls  for  at  least  1  bed  for 
every  annual  death  the  hospital  provisions  of  the  state  would  seem 
to  be  still  inadequate.  Rhode  Island  is  much  better  off  than  most 
states,  however.     In  New  York  State  (outside  of  New  York  City) 

39 


the  corresponding  ratios  are  1  bed  for  1600  population  or  1  bed  for 
every  1.9  deaths  from  tuberculosis.  Furthermore,  the  hospital 
beds  now  provided  are  by  no  means  fully  occupied.*  At  Hillsgrove 
the  70  beds  have  been  regularly  filled  to  capacity  and  at  one  time 
20  additional  cots  were  in  use.  At  the  State  Almshouse  two  pa- 
vilions containing  46  beds  are  usually  filled.  At  the  Providence 
City  Hospital,  however,  there  have  generally  been  extra  beds  avail- 
able and  the  Wallum  Lake  wards  have  of  late  been  only  two-thirds 
filled,  as  indicated  by  Table  XIV  below. 

Prior  to  1917  the  beds  at  these  two  institutions  were  fairly  well 
utilized  but  during  the  past  three  years  there  has  been  a  falling  off 
in  cases  at  the  City  Hospital,  and  no  increase  at  Wallum  Lake  to 
correspond  with  the  opening  of  the  new  building  for  advanced  cases 
in  1918. 

Empty  beds  have  been  common  in  many  sanatoria  as  a  result  of 
the  decrease  in  tuberculosis  during  the  last  two  years  and  of  the 
high  wages  which  tempt  patients  to  stay  at  work  when  they  should 

TABLE  XIV. 


Utiliz 

ATIOX     OF     H 

OSPITAL     AND     SANATORIUM 

Facil 

ITIES 

Wallum  La 

ke 

Ci 

ity  Ho£ 

ipital 

Year 

Beds 

i  available 

Bed 

s  occupied 

Beds 

avail 

lable 

Bed! 

3  OC 

1910 

130 

123 

35 

29 

1911 

140 

127 

35 

33 

1912 

140 

134 

60 

41 

1913 

140 

115 

60 

52 

1914 

140 

119 

60 

54 

1915 

157 

146 

60 

60 

1916 

208 

180 

60 

61 

1917 

216 

201 

60 

45 

1918 

360 

222 

60 

44 

1919 

360 

232 

60 

55 

be  in  the  hospital.  Nine  New  York  county  hospitals  for  which  I 
have  obtained  data  show  from  5  per  cent  to  40  per  cent  of  empty 
beds  in  1919,  with  an  average  of  23  per  cent.  Only  one  of  the  nine, 
however,  shows  as  high  a  ratio  as  Wallum  Lake  (36  per  cent  vacant 
beds). 

In  the  best  sanatoria,  treatment  is  still  in  as  great  demand  as 
ever.     At  the  Gaylord   Farm  Sanatorium  in   Connecticut  97   per 


*The  intensive  work  carried  out  at  Framinjham  has  indicated  that  an  ideal  provision  would 
be  two  beds  for  each  annual  death. 

40 


cent  of  the  beds  were  occupied  on  the  average  during  both  1918  and 
1919,  in  spite  of  an  increased  capacity  of  14  beds  during  the  latter 
year.  In  Dutchess  County,  New  York,  the  Samuel  Bowne  Me- 
morial Hospital  reports  99  per  cent  utilization  of  facilities. 

In  order  to  obtain  a  better  idea  of  the  actual  degree  of  hospitaliza- 
tion accomplished  from  time  to  time,  in  the  state  as  a  whole,  and  in 
its  various  areas,  Mr.  Chandler  has  prepared  Tables  XV  and  XVI, 
which  give  the  admission  rate  at  Wallum  Lake  and  Hillsgrove, 
respectively,  from  each  city  or  tovvn  in  the  state  for  each  year  from 
1910  to  1919.  Similar  data  for  the  Providence  City  Hospital  are 
combined  with  the  yearly  averages  for  all  admissions  at  Wallum 
Lake  and  Hillsgrove  for  the  various  years  in  Table  XVII. 


41 


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43 


TABLE  XVII. 
Admission   Rate  to  Tuberculosis   Hospitals  and  Sanatoria. 

Admissions  per  100,000  Population. 

Ten 
Year      1910    1911     1912    1913    1914    1915    1916    1917    1918     1919     Years 
Rate         92        97       100      102      117      115      125      137      153      133        117 

The  admission  rates  show  a  practically  steady  increase  from  1910 
to  1918,  with  a  large  increment  in  1918,  when  the  new  pavilion  at 
Wallum  Lake  was  opened.  In  1919  there  was  a  falling  off,  coinci- 
dent with  the  decreased  incidence  of  tuberculosis  indicated  by  the 
mortality  rates  previously  cited.  This  decrease  in  the  incidence 
of  tuberculosis  characteristic  of  the  year  1919  (and  apparently  con- 
tinuing in  1920)  is  presumably  due  to  the  combined  influences  of 
prosperity,  prohibition  and  military  training.  It  would  naturally 
lead  to  a  decrease  in  sanatorium  treatment,  other  things  being 
equal,  but  since  we  know  that  in  the  best  of  times  a  very  large  num- 
ber of  cases  of  tuberculosis  which  would  benefit  by  institutional 
care  fail  to  receive  it,  the  present  situation  should  merely  serve  as 
an  opportunity  for  developing  the  use  of  hospital  and  sanatorium 
facilities  by  classes  of  cases  which  have  failed  to  avail  themselves 
of  such  advantages  in  the  past. 

The  general  situation  with  regard  to  the  hospitalization  of  tu- 
berculosis in  Rhode  Island  is,  however,  extraordinarily  good  as 
compared  with  other  states.  Connecticut  in  1918  had  a  total  tu- 
berculosis admission  rate  of  only  78  per  100,000  population;  and  18 
counties  of  New  York  State  for  which  we  obtained  the  1919  records 
had  an  average  admission  rate  of  only  109  per  100,000  population. 
The  Rhode  Island  figures  give  91  admissions  per  100  annual  deaths, 
the  New  York  figures  80  and  the  Connecticut  figures  only  53,  a 
splendid  showing  for  Rhode  Island. 

Turning  to  the  variations  in  degrees  of  hospitalization  apparent 
in  different  areas  within  the  state  we  have  prepared  in  Table  XVIII 
comparative  figures  for  the  larger  cities  and  for  the  rest  of  the  state. 
In  all  these  tabulations  the  cases  cared  for  at  the  state  institution 
of  Cranston  are  omitted,  but  the  totals  would  be  too  small  to  affect 
our  ratios  in  material  degree. 

It  appears  from  Table  XVIII  that  hospitalization  of  tuberculosis 
cases,  in  proportion  to  the  incidence  of  the  disease  (ratio  of  annual 
admissions  per  100  annual  deaths),  is  most  complete  in  Providence, 
with  Woonsocket,  Central  Falls,  Pawtucket  and  Newport  follow- 

44 


ing  in  the  order  named,  while  Cranston  and  the  rural  districts  lag 
notably  behind.  This  is  exactly  what  would  be  expected  from  the 
fact  that  clinic  and  nursing  services  are  most  highly  developed  in 
Providence  and  are  almost  lacking  in  Cranston  and  in  the  other 
rural  districts. 

In  general  we  may  conclude,  in  regard  to  the  quantitative  ade- 
quacy of  institutional  facilities,  that  while  the  number  of  hospital 
and  sanatorium  beds  provided  is  not  sufficient  for  the  care  of  all 
the  patients  who  ought  ideally  to  receive  institutional  treatment, 
there  are  today  more  beds  available  than  are  being  utilized.  The 
immediate  problem  is  therefore  the  development  of  machinery 
v,'hich  will  get  more  patients  into  the  hospitals  and  sanatoria,  an 
end  which  can  best  be  attained  by  the  impro\'ements  in  clinic  ser- 
vice which  have  been  suggested  above;  for  the  clinic  if  properly 
organized  should  be  the  primary  feeder  of  the  sanatorium. 

TABLE  XVIII. 

Admission  Rate  to  Tuberculosis  Hospitals  and  Sanatoria. 

Average  1910-1919 


O  'S  t  s  ^  ^  "  ° 

o  5  o  "  2  i;  ^ 

Ah  P-i  >  ^  (U  o 

Admission  rate  per 

100,000  population      135  89  111  74  44  105  69 

Admission  rate  per 

100  annual  deaths         69  56  64  56  46  64  50 

The  main  service  which  the  hospital  for  advanced  cases  of  tuber- 
culosis renders  is  the  removal  of  dangerous  open  cases  from  the 
proximity  of  other  persons,  and  particularly  of  children,  who  might 
be  endangered  by  their  presence  in  the  community  at  large.  The 
object  of  sanatorium  treatment  on  the  other  hand  is  the  restora- 
tion of  the  health  of  the  patient;  and  the  attainment  of  this  end  de- 
pends on  the  beginning  of  treatment  at  a  sufficiently  early  stage  in 
the  treatment  of  the  disease.  The  next  point  in  which  we  are  in- 
terested is,  therefore,  the  condition  of  the  patients  admitted,  par- 
ticularly at  W'allum  Lake,  since  the  Providence  City  Hospital  and 
the  St.  Joseph's  Annex  are  primarily  designed  for  the  hospitaliza- 
tion of  advanced  cases. 

The  admirable  statistics  of  the  State  Sanatorium  at  Wallum 
Lake  give  the  following  classification  of  cases  admitted,  in  ikt- 
centages  of  total  admissions  for  each  year: 

4.S 


1915 

1916 

1917 

Incipient  cases 

7 

4 

1 

Moderately  advanced  cases 

80 

82 

83 

Far  advanced  cases 

13 

13 

15 

The  average  duration  of  disease  before  admission  was  estimated 
at  21.8  months  and  24.5  months  for  the  years  1916  and  1917, 
respectively. 

For  the  past  two  years  the  patients  have  been  classified  accord- 
ing to  the  newer  terminology  as  follows: 

Condition  on  Admission  1918  1919 

I  A  38  33 
B  34  45 
C  4  3 

II  A  42  35 
B  211  190 
C  32  24 

III  A  5  4 
B  61  72 
C  110  91 

Other  29  55 

The  data  for  1915,  1916  and  1917  are  most  important  for  our  pur- 
poses, since  they  include  only  sanatorium  cases,  the  new  ward  for 
advanced  cases  having  been  opened  in  1918.  They  are  distinctly 
discouraging  from  the  standpoint  of  curability  of  the  patients  ad- 
mitted, since  only  from  1  to  7  per  cent  of  the  cases  fall  in  the  in- 
cipient class.  Statistics  from  many  institutions  show  that  of  in- 
cipient cases  75  per  cent  or  over  may  be  expected  to  show  improve- 
ment under  proper  sanatorium  treatment,  while  with  moderately 
advanced  cases  the  proportion  falls  to  50  to  60  per  cent,  and  with  far 
advanced  cases  to  40  per  cent  or  less.  It  is  unfortunately  true  that 
tuberculosis  cases  reach  all  our  sanatoria  at  a  deplorably  late  stage, 
but  conditions  are  not  usually  as  bad  as  in  Rhode  Island.  At  the 
Gaylord  Farm  Sanatorium  in  Connecticut  the  figures  for  1917, 
1918  and  1919  show,  respectively,  19  per  cent,  14  per  cent  and  11 
per  cent  of  the  cases  admitted  to  be  incipient,  67  per  cent,  69  per 
cent  and  74  per  cent  moderately  advanced  and  14  per  cent,  17  per 
cent  and  14  per  cent,  respectively,  to  be  far  advanced.  Even  the 
four  state  sanatoria  of  Connecticut,  which  admit  all  types  of  cases, 
report  for  1918,  7  per  cent  of  incipient  cases,  although  the  propor- 
tion of  far  advanced  cases  (52  per  cent)  is  also  much  higher  than 
at  Wallum  Lake. 

46 


At  the  Providence  City  Hospital  conditions  are  naturally  even 
less  encouraging  than  at  Wallum  Lake.  For  the  three  years  1917 
to  1919  between  1  per  cent  and  3  per  cent  of  the  patients  admitted 
have  been  incipient  cases,  between  10  per  cent  and  22  per  cent 
moderately  advanced  cases  and  between  77  per  cent  and  87  per 
cent  far  advanced  cases.  This  is  naturally  to  be  expected,  since 
the  City  Hospital  tuberculosis  pavilion  is  primarily  intended  for 
isolation  rather  than  for  curative  treatment. 

The  next  criterion  which  may  properly  be  applied  in  estimating 
the  efficiency  of  sanatorium  and  hospital  treatment  is  the  length  of 
stay  in  the  institution ;  for  it  may  be  assumed  under  present  condi- 
tions of  sanatorium  management  that  an  average  of  six  months' 
residence  will  be  necessary  in  order  to  effect  a  reasonable  proportion 
of  successful  treatments. 

At  the  Providence  City  Hospital  and  at  Hillsgrove  the  average 
period  of  residence  is  of  course  short,  since  the  cases  received  are 
mostly  in  an  advanced  stage;  and  at  Wallum  Lake  the  opening  of 
the  ward  for  advanced  cases  in  1918  was  followed  by  a  sharp  fall  in 
the  average  for  the  institution  as  a  whole.  Incidentally  it  may  be 
remarked  that  it  would  be  helpful  to  keep  and  tabulate  separately 
the. statistics  for  the  sanatorium  and  hospital  wards  at  Wallum 
Lake,  since  the  aims  of  the  two  types  of  treatment  and  the  criteria 
by  which  they  may  be  judged  are  so  distinct,  although  Dr.  Barnes 
feels  that  certain  practical  considerations  make  such  a  sharp  separa- 
tion undesirable.  If  we  exclude  1918  and  1919  from  consideration, 
however,  the  average  period  of  residence  for  the  years  1910-1917  at 
Wallum  Lake  is  still  only  156  days. 

This  period  of  residence  is  too  short  to  permit  of  the  maximum 
benefit  from  sanatorium  treatment;  but  it  is  a  record  no  worse  than 
is  reported  from  many  instifutions  of  similar  type.  Recent  sta- 
tistics have  shown  an  average  residence  of  129  days  at  Wildwood 
Sanatorium,  158  days  at  the  New  Jersey  Sanatorium  and  160  days 
at  Hebron,  Maine.  On  the  other  hand,  New  Hampshire  reports 
175  days,  Suffolk  County,  New  York,  204  days,  Monroe  County, 
New  York,  214  days.  North  Reading,  213  days,  Rutland,  269  days. 
At  Gaylord  Farm  the  average  stay  for  all  patients  was  182  days  in 
1917,  200  days  in  1918  and  194  days  in  1919.  It  is  clear  that  the 
short  period  of  residence  at  Wallum  Lake  is  a  distinct  handicap  to 
the  efficiency  of  the  institution;  and  this  conclusion  is  emphasized 
by  the  fact  that  of  the  total  patients  discharged  41  per  cent  in  1915, 

47 


54  per  cent  in  1916,  and  53  per  cent  in  1917,  left  against  advice. 
The  period  of  residence  at  Wallum  Lake  is  also  however  affected 
by  the  fact  that  patients  who  are  definitely  failing  are  frequently 
forced  to  go  to  Hillsgrove  or  the  Providence  City  Hospital  to  make 
room  for  more  favorable  cases.  During  the  years  1908-1912,  in- 
clusive, 16  per  cent  of  the  discharged  patients  were  forced  out  in 
this  way. 

Considering  the  fact  that  so  many  of  the  patients  at  Wallum 
Lake  are  admitted  too  late  in  the  course  of  the  disease  and  leave  too 
.soon  for  a  cure  to  be  effected,  the  immediate  results  of  the  treatment 
are  surprisingly  favorable.  For  simplicity  we  have  arranged  the  dis- 
charged cases  at  Wallum  Lake  (and  also  at  the  two  hospitals  for 
advanced  cases)  under  three  main  headings:  (a)  improved  (including 
arrested  and  apparently  cured  and  quiescent  cases),  (b)  dead,  and 
(c)  all  other  groupings  (including  a  few  cases  which  were  non- 
tuberculous  or  doubtful  in  nature).  The  results  expressed  in  per- 
centages are  given  in  Table  XX. 

At  the  Providence  City  Hospital  and  at  Hillsgrove  a  little  more 
than  half  the  patients  die  and  less  than  a  quarter  show  improve- 
ment, a  result  which  is  about  what  might  be  expected  from  the  type 
of  cases  admitted.  At  Wallum  Lake  the  opening  of  the  ward  for 
advanced  cases  in  1918  naturally  led  to  a  marked  decrease  in  the 
proportion  of  improved  cases.  Again  the  importance  of  keeping 
distinct  the  statistics  of  sanatorium  and  hospital  cases  at  Wallum 
Lake  is  made  apparent.  The  only  fair  basis  of  judgment  as  re- 
gards sanatorium  treatment  is  to  consider  the  statistics  for  Wallum 

TABLE  XIX. 
Average  Length  of  Stay  in  Sanatoria  and  Hospitals. 


Wallum 

Lake 

Hillsgrove 

Providence  C 

ity  Hospital 

1910 

153  days 

50  days 

36  days 

1911 

151 

81  " 

82  ' 

1912 

149 

85  " 

131  ' 

1913 

155 

113  " 

109  ' 

1914 

138 

79  " 

94  ' 

1915 

169 

134  " 

117  ' 

1916 

154 

109  " 

99  ' 

1917 

179 

111  " 

92  ' 

1918 

138 

221  " 

90  ' 

1919 

139 

151  " 

71  ' 

Average 

152 

113  " 

92  ' 

48 


TABLE  XX. 

Condition  of  Patients  Discharged  from  Hospitals  and  Sanatoria. 

(Percentages  of  Total). 


Wallum  Lake 

Providence  City 

Hospital 

Hillsgrc 

ve 

Year 

Improved 

Dead 

Others 

Improved  Dead 

Others 

Improved 

Dead 

Others 

1910 

74 

2 

24 

25 

60 

15 

50 

50 

0 

1911 

70 

1 

28 

25 

61 

13 

23 

58 

19 

1912 

73 

3 

25 

28 

55 

17 

16 

55 

29 

1913 

65 

1 

34 

23 

54 

23 

14 

47 

39 

1914 

61 

1 

37 

21 

48 

31 

9 

53 

38 

1915 

62 

4 

34 

27 

54 

19 

15 

52 

33 

1916 

63 

4 

32 

21 

58 

20 

16 

49 

35 

1917 

61 

5 

34 

25 

53 

22 

14 

61 

25 

1918 

46 

26 

28 

18 

53 

29 

22 

52 

26 

1919 

42 

26 

32 

19 

54 

27 

32 

40 

28 

Ten  years 

62 

7 

31 

23 

55 

22 

21 

52 

27 

Lake  prior  to  1918.  The  averages  for  1910-1917  are  as  follows: 
improved,  66  per  cent;  dead,  3  per  cent;  all  others,  31  per  cent. 

The  heading  "improved"  as  used  in  Table  XX  is  of  course  a  very- 
vague  term  and  the  Wallum  Lake  cases  of  this  type  have  been  fur- 
ther subdivided  in  Table  XXL  It  appears  from  this  tabulation 
that  only  3  per  cent  of  the  sanatorium  cases  treated  between  1910 
and  1917  were  definitely  considered  as  cured  and  only  17  per  cent 
as  apparently  arrested,  12  per  cent  being  quiescent  and  34  per  cent 
merely  improved. 

At  the  Gaylord  Farm  Sanatorium,  the  average  results  for  the 
three  years  1917  to  1919  were  as  follows:  cases  apparently  arrested, 
8  per  cent;  quiescent,  39  per  cent;  improved,  32  per  cent;  dead,  2 
per  cent;  all  others,  19  per  cent. 

The  success  of  sanatorium  treatment  can  not,  however,  be 
judged  solely  by  the  somewhat  arbitrary  classification  of  the  con- 
dition of  the  patients  on  discharge.  The  real' test  is  the  fate  of  the 
patients  when  they  return  to  the  conditions  of  community  life  out- 
side. Dr.  Barnes,  the  superintendent  of  the  State  Sanatorium,  has 
conducted  most  valuable  studies  of  the  condition  of  his  patients 
after  discharge,  which  were  published  in  the  reports  of  the  Trustees 
of  the  Sanatorium  up  to  1917.  The  discontinuance  of  these  full 
statistical  reports  since  1917  (due  to  misguided  parsimony  on  the 
part  of  the  state  authorities)  is  a  real  misfortune  since  they  con- 
stituted a  real  contribution  to  this  important  subject  and  were  much 
to  the  credit  of  the  state  of  Rhode  Island. 

In  Table  XXII  we  have  summari/.ed  the  data  presented  in  Dr. 
Barnes'  report  for  1917,  covering  a  total  of  3088  cases  admitted  be- 
tween January  1,  1906,  and  January  1,  1917,  showing  the  condition 

49 


TABLE  XXI. 
Condition    of    Patients    Discharged   from 
(Percentage  of  Total) 
Year  Apparently  Cured       Apparently  Arrested        Quiescent 

35 
30 
27 
11 

6 

5 
10 
13 


1910 

7 

1911 

9 

1912 

7 

1913 

1914 

1915 

1916 

1917 

1918 

1919 

Ten  years 

2 

Eight  years 

1910-1917 

3 

3 
15 

17 


18 
17 
23 
23 
18 
14 
14 
13 

12 


Wallum    Lake. 


Improved     Dead      Others* 


32 
31 
40 
36 
38 
35 
31 
30 
24 
25 
32 

34 


2 
1 
3 
1 
1 
4 
4 
5 
26 
26 
7 


24 
28 
25 
34 
37 
34 
32 
34 
28 
32 
31 

31 


*Chiefly  "unimproved." 


TABLE  XXIL 

Results  of  Sanatorium  Treatment  at  Wallum  Lake. 

3088  Patients  Admitted  1906-1916. 

Percentages  for  each  Admission  Group. 


Condition  on 

Condition  on 

Condition  Jan.  1,  1918. 

Admission               Discharge 

Well 

Living  and 

Living,  not 

Un- 

Working 

Working 

Dead 

known 

f  Apparently  cured 

15 

4 

0 

4 

3 

.   .                 Apparently  arrested 

14 

3 

3 

6 

3 

"T'"\        Quiescent 

3 

1 

2 

1 

1 

(227  cases)     1  i.,,p,,,,d 

15 

4 

4 

5 

4 

Unimproved 

2 

4 

0 

3 

0 

f  Apparently  cured 

2 

1 

0 

0 

0 

Moderately      Apparently  arrested 

7 

3 

2 

10 

2 

Advanced       <  Quiescent 

2 

2 

2 

3 

0 

(2558  cases)]     Improved 

4 

4 

4 

23 

2 

[  Unimproved 

1 

1 

2 

22 

1 

Apparently  cured 

0 

0 

0 

0 

0 

Apparently  arrested 

1 

0 

0 

3 

0 

Far  Advanced , 
(303  cases) 

Quiescent 

0 

0 

0 

1 

0 

Improved 

0 

0 

1 

17 

1 

,  Unimproved 

0 

0 

0 

73 

1 

of  these  patients  on  admission,  on  discharge  and  on  January  1, 
1918, — five  years  on  the  average  since  they  began  treatment.  We 
have  reduced  all  these  figures  to  a  percentage  basis,  considering 
each  of  the  three  main  groups  admitted  as  100  per  cent. 


50 


It  is  apparent  from  this  very  interesting  table  that,  of  the  incipient 
cases  admitted,  two-thirds  of  those  who  could  be  located  were  found 
to  be  well  or  alive  and  at  work,  a  very  encouraging  record.  On  the 
other  hand,  of  the  moderately  advanced  cases,  over  60  per  cent  of 
those  that  could  be  traced  were  dead  and  only  28  per  cent  were  well 
or  living  and  working;  while  of  the  far  advanced  cases  63  per  cent 
were  dead  and  28  per  cent  were  well  or  at  least  alive  and  at  work. 

From  another  standpoint  we  may  conveniently  divide  the  whole 
series  into  nine  main  groups,  first  on  the  basis  of  condition  on  ad- 
mission and  second  on  the  basis  of  condition  on  discharge,  group- 
ing apparently  cured,  arrested  and  apparently  arrested  cases  to- 
gether as  presumably  favorable, — grouping  quiescent  and  improved 
cases  as  doubtful,  and  considering  unimproved  cases  as  clearly  un- 
favorable. 


TABLE  XXIII. 
Efficienxy  of  Sanatorium  Treatment  at  Wallum  Lake 
3088  patients  admitted  1906-1916 
Percentages  of  Total  Group. 

Condition  on     Condition  on  •        Condition  Jan.  1,  1918 

Admission  Discharge  Per  cent  Per  cent 

well  or  living   living,  not    Per  cent 
and  at  work       working         dead 
2  1 

2 


Incipient 


Moderately 
Advanced 


Far  Advanced 


Favorable 

Doubtful 

Unfavorable 


Favorable 

Doubtful 

Unfavorable 

Favorable 

Doubtful 

Unfavorable 


Total  all  cases: 


10 

10 

1 


25 


9 
21 
19 

2 

7 

59 


Per  cent 
unknown 


Table  XXIII  indicates  that  of  the  patients  discharged  from 
Wallum  Lake  during  the  period  1906-16,  only  5  per  cent  were  in- 
cipient cases  at  the  time  of  admission.  Four  per  cent,  out  of  this 
5  per  cent,  were  living  and  at  work  after  an  average  of  five  years. 
Nine  per  cent  were  far  advanced  cases  at  the  time  of  admission  and 
practically  all  were  dead  after  an  average  of  five  years.  The  great 
bulk  of  the  cases  (84  per  cent)  were  moderately  advanced  cases;  of 
these  23  per  cent  were  in  a  favorable  condition  on  discharge,  and  10 


51 


per  cent  remained  alive  and  able  to  work;  39  per  cent  were  in  a 
doubtful  condition  (quiescent  or  improved)  on  discharge  and  10 
per  cent  remained  alive  and  able  to  work;  22  per  cent  were  unim- 
proved on  discharge  and  only  1  per  cent  remained  alive  and  able 
to  work  after  an  average  of  five  years.  Taking  all  groups  together 
it  appears  that  sanatorium  treatment  effected  a  fairly  permanent 
cure  in  25  per  cent  of  the  cases  discharged,  that  59  per  cent  of  all 
cases  discharged  were  dead  after  an  average  of  five  years,  while  8 
per  cent  were  alive  but  not  able  to  work,  and  6  per  cent  were  lost. 
The  actual  result  of  institutional  treatment  in  this  case  is,  there- 
fore, to  save  about  one  quarter  of  the  cases  discharged. 

These  results  are  disappointing;  and  it  is  evident  that  the  reasons 
for  the  failure  to  effect  a  larger  percentage  of  cures  is  a  twofold  one. 
First,  of  the  3088  patients  covered  in  Table  XXIII,  only  5  per  cent 
were  incipient  cases  on  admission;  and  second,  only  26  per  cent  re- 
mained in  the  institution  until  the  disease  was  apparently  cured  or 
arrested. 

Where  sanatorium  treatment  is  secured  early  and  continued  for 
a  sufficient  period  very  different  results  are  obtained.  Dr.  F.  B. 
Trudeau  reports  (American  Review  of  Tuberculosis,  4,  518)  that  of 
979  consecutive  cases  discharged  from  Saranac  Lake  between  1907 
and  1913,  64  per  cent  were  well  in  1918,  13  per  cent  living,  21  per 
cent  dead  and  1  per  cent  lost. 

Table  XXIV  presents  the  results  of  treatment  at  Gaylord  Farm 
in  a  form  comparable  to  Table  XXIII.  Arrested  cases  have  been 
called  "favorable,"  improved  cases  "doubtful,"  and  progressive 
cases  "unfavorable,"  in  estimating  the  condition  on  discharge.  In 
the  classification  of  the  cases  five  years  or  more  (5-12  years)  after 
discharge  the  "still  arrested"  group  corresponds  fairly  well  with  the 
"living  and  at  work"  group  in  Table  XXIII.  The  "improved  or 
progressive"  group  may  be  compared  with  the  "living  but  not  work- 
ing" group  in  Table  XXIII.  On  this  basis  Gaylord  Farm  appears 
to  effect  a  permanent  cure  for  44  per  cent  of  its  patients  against  25 
per  cent  at  Wallum  Lake,  and  this  result  is  made  possible,  not  be- 
cause the  actual  treatment  given  is  superior  to  that  at  Wallum  Lake, 
but  primarily  because  22  per  cent  of  the  Gaylord  Farm  patients 
were  incipient  at  entrance  against  5  per  cent  at  Wallum  Lake. 
It  is  the  type  of  patient  treated  that  makes  the  primary  difference, 
Wallum  Lake,  like  nine  out  of  ten  sanatoria  the  country  over  is  deal- 
ing with  patients  most  of  whom  are  so  far  advanced  as  to  be  hope- 

52 


less,  while  specially  favored  institutions  like  Saranac  Lake  and  Gay- 
lord  Farm  show  what  can  be  done  by  sanatoria  which  really  treat 
tuberculosis  in  its  incipient  stage. 

It  is  also  certain  that  the  type  of  patients  treated  at  Saranac  and 
at  Gaylord  Farm  go  back  to  much  more  favroable  home  conditions 
than  the  average  of  those  treated  at  Wallum  Lake. 

TABLE  XXIV. 

Efficien'CY  of  Sanatorium  Tre.\tment  at  Gaylord  Farm 

817  Cases  admitted  prior  to  1912. 

Percentage  of  total  group. 

Condition  Condition  Condition  May  1,  1917 

on  admission       on  discharge     Percentage     Percentage  Per-  Per- 

still  improved  or      centage        centage 

arrested       progressive  dead         unknown 

Favorable 11 1 1 

Incipient  Doubtful 7 ;...   1 1 

Unfavorable 

Moderately  Favorable 17 1 8.  .  ..-. 1 

Advanced  Doubtful 8 1 12 1 

Unfavorable 1 8 

Far  Advanced      Favorable 2 

Doubtful 6. 

Unfavorable 9 


44  2  47  4 

The  State  Sanatorium  at  Wallum  Lake  is  an  admirable  institu- 
tion. It  was  constructed  on  an  unusual  and  economical  plan.  It 
is  ably  and  efficiently  administered,  and  the  scientific  quality  of  the 
work  done  by  Dr.  Barnes  and  his  assistants  is  of  the  highest  order. 
Doctors  Pinckney  and  Hamblet,  who  come  into  most  direct  contact 
with  the  patients,  are  untiring  in  their  devotion.  Yet,  in  the  case 
of  more  than  three  fourths  of  the  patients  admitted,  this  institution 
fails  of  attaining  satisfactory  results.  The  remedy  for  this  situa- 
tion can  only  be  found  by  securing  the  treatment  of  patients  at  an 
earlier  stage  in  the  development  of  the  disease  and  by  continuing 
that  treatment  until  the  disease  is  definitely  arrested.  The  earlier 
beginning  of  treatment  must  lie  chiefly  with  agencies  outside  the 
sanatorium  itself,  with  the  state  and  municipal  health  authorities, 
with  the  clinics  and  public  health  nursing  associations  and  with  the 
voluntary  anti-tuberculosis  organizations  of  the  State.     The  task 

53 


of  holding  patients  until  they  are  cured  is  largely  the  problem  of 
the  sanatorium  itself  (although  the  success  attained  will  naturally 
be  affected  by  economic  conditions  and  by  the  intelligence  of  the 
patients) ;  and  any  improvements  in  psychological  atmosphere  which 
will  keep  old  patients  happy  will  indirectly  make  it  easier  to  per- 
suade new  patients  to  enter  the  institution. 

In  the  past,  far  too  little  attention  has  been  paid  to  the  problem 
of  the  mental  attitude  of  the  sanatorium  inmate,  as  a  man  or  a 
woman,  rather  than  a  patient.  The  experience  of  the  social 
workers  of  the  Red  Cross  in  the  hospitals  maintained  for  tuber- 
culous soldiers  has  shown  how  much  may  be  accomplished  by 
specialists  in  the  social  service  field.  The  busy  physicians  respon- 
sible for  the  medical  work  of  a  large  sanatorium  cannot  find  the 
time,  even  if  they  have  the  special  gifts  and  the  special  knowledge, 
to  write  letters,  to  clear  up  financial  and  family  problems,  to  give 
personal  cheer  and  counsel.  I  am  inclined  to  believe  that  nothing 
would  contribute  more  to  the  success  of  the  State  Sanatorium  than 
the  appointment  of  a  medical  social  worker  to  care  for  the  personal 
life  of  the  patients  and  to  make  it  easy  and  pleasant  for  them  to  re- 
main at  Wallum  Lake  until  their  cure  is  completed.  Ultimately 
such  an  officer  should  form  a  part  of  the  regular  official  staff  of  the 
institution;  but  until  the  worth  of  the  position  has  been  conclusively 
demonstrated  I  would  recommend  that  the  Rhode  Island  Tubercu- 
losis Association  pay  the  salary  of  a  medical  social  worker  to  serve 
at  the  State  Sanatorium  for  the  purposes  outlined. 

There  is  one  peculiar  handicap  under  which  the  sanatorium  at 
Wallum  Lake  suffers;  and  that  is  its  distance  from  the  centers  of 
population  and  the  consequent  difficulty  of  access  for  the  families 
and  friends  of  patients.  Even  from  Providence  a  trip  to  Wallum 
Lake  consumes  an  entire  day,  with  existing  train  service,  and  for 
residents  of  other  parts  of  the  state  two  days  and  one  or  two  nights 
would  be  required.  The  opening  of  some  regular  means  of  com- 
munication would  make  it  easy  for  patients  to  receive  visits  and 
would  greatly  assist  in  securing  earlier  and  longer  treatment. 
Again  there  seems  a  distinct  field  for  the  Rhode  Island  Tuberculosis 
Association;  and  I  would  urge  that  this  organization  give  serious 
consideration  to  the  possibility  of  arranging  for  daily  automobile 
service  to  and  from  Wallum  Lake. 

Prior  to  the  effective  establishment  of  such  transportation  ser- 
vice, it  is  necessary,  however,  to  provide  for  substantial  improve- 

54 


ment  in  the  highways  leading  to  the  sanatorium.  I  am  informed 
that  the  road  from  Pascoag  to  Wallum  Lake  is  almost  impassable 
for  four  to  six  months  of  the  year ;  and  it  would  seem  proper  to  urge 
upon  the  Legislature  the  pressing  need  for  such  repairs  as  shall  put 
this  highway  into  proper  condition. 

Finally  it  should  be  pointed  out  that  there  is  still  another  prob- 
lem to  be  considered  in  connection  with  sanatorium  treatment,— 
the  after  care  of  patients  who  have  been  discharged.  In  Provi- 
dence and  the  other  large  cities  of  Rhode  Island  discharged  cases 
are  well  followed  up  by  the  public  health  nursing  organizations; 
but  experience  teaches  us  that  of  the  patients  discharged  as  ar-^ 
rested,  quiescent  or  improved  there  is  a  certain,  fairly  large,  pro- 
portion who  will  continue  in  good  health  while  living  under  ideal 
sanitary  hygienic  conditions,  but  who  will  go  steadily  down  under 
the  ordinary  conditions  of  urban  and  industrial  life.  For  such 
cases  salvation  lies,  not  in  any  temporary  treatment,  but  in  a  per- 
manent change  in  the  conditions  of  their  daily  life.  Long  con- 
tinued sanatorium  treatment  for  such  patients  is  neither  necessary 
nor  desirable.  What  they  need  is  the  opportunity  for  normal  family 
life  and  for  the  maximum  of  self-support,  under  environmental  and 
industrial  and  social  conditions  which  make  it  possible  for  them  to 
retain  their  new-found  health.  It  is  now  generally  recognized  that 
the  solution  of  this  problem  lies  in  the  establishment  of  industrial 
colonies,  such  as  Dr.  Pattison  has  so  admirably  projected  in  the 
American  Review  of  Tuberculosis  for  July,  1919,  or  in  the  provision 
of  special  industrial  facilities,  like  those  furnished  by  the  Com- 
mittee for  the  Relief  of  the  Jewish  Tuberculous  in  New  York  City, 
or  of  special  housing  facilities,  like  those  established  by  the  Associa- 
tion for  Improving  the  Condition  of  the  Poor,  also  in  New  York 
City.  Such  projects  must  be  worked  out  for  the  future  with  much 
thought  and  discrimination.  I  would  suggest  that  those  who  are 
interested  in  the  furtherance  of  anti-tuberculosis  work  in  Rhode 
Island  could  render  a  most  important  service  by  undertaking  a 
study  of  the  problem  of  the  provision  of  proper  conditions  for  the 
family  and  industrial  life  of  arrested  and  quiescent  cases  of  tuber- 
culosis in  Rhode  Island,  with  a  view  to  formulating  a  definite 
plan  of  action  at  a  later  date. 

55 


VI.     PUBLIC  HEALTH  NURSING  IN  RHODE  ISLAND  AND 

ITS  RELATION  TO  THE  ANTI-TUBERCULOSIS 

CAMPAIGN. 

Next  to  the  clinic  and  the  sanatorium  the  pubHc  health  nurse  is 
the  most  vital  factor  in  the  anti-tuberculosis  campaign.  Her  work 
is  essential  in  the  discovery  of  new  cases  and  in  bringing  them  in 
contact  with  the  clinic  and  the  sanatorium,  in  the  active  follow-up 
and  bedside  care  of  cases  under  the  charge  of  the  clinic,  and  in  the 
after  care  and  continued  instruction  of  discharged  arrested  cases. 
A  general  review  of  the  public  health  nursing  facilities  of  the  state 
is  therefore  an  essential  part  of  our  survey. 

So  far  as  we  have  been  able  to  learn, — chiefly  from  the  very  ac- 
curate information  in  the  hands  of  the  Providence  District  Nursing 
Association, — there  are  at  present  112  public  health  nurses  in  the 
state  of  Rhode  Island,  exclusive  of  the  industrial  nurses,  who  will 
be  considered  separately.  They  are  distributed  in  proportion  to 
population  as  indicated  in  Table  XXV. 

Wherever  the  development  of  public  health  nursing  has  been 
attempted  on  an  intensive  scale,  as  in  selected  Health  Center  Dis- 
tricts of  Boston,  New  York  and  New  Haven,  it  has  been  found  that 
a  group  of  1500  to  2000  persons  is  the  largest  that  can  be  cared  for 
in  a  really  adequate  manner.  The  supply  of  nurses  is  everywhere, 
however,  deplorably  short  of  the  need,  and  as  matters  stand  today 
any  community  which  has  one  public  health  nurse  for  every  4000 
to  5000  population  is  relatively  well  served.     Providence,  the  Paw- 

TABLE  XXV. 
Public  Health  Nursing  Service  in  Rhode  Island. 

Number  Nurses  Population    per    Nurse 

Providence  66  3600 

Pawtucket,  Central  Falls,  and 

Cumberland 
Woonsocket 
Pawtuxet  Valley 
East  Providence 
Newport 
Cranston 
Westerly 

Fourteen  other  towns* 
Rest  of  state 

State  Health  Department 

Total 112  5400 

*Barrington,  Bristol,  Burrillville,  East  Greenwich,  Johnston,  Little  Compton,  Middletown, 
North  Kingstown,  North  Providence,  Smithfield,  South  Kingstown,  Tiverton,  Warren,  and 
Warwick. 

56 


9 

10900 

6 

7200 

4 

5200 

3 

7100 

4 

7500 

2 

14500 

2 

5000 

14 

5800 

0 

20000  persons  with  no 

public  health  nurse 

2 

tuxet  Valley  (Coventr\-  and  West  Warwick)  and  Westerly  are, 
therefore,  ia  reasonably  good  condition,  so  far  as  public  health 
nursing  service  is  concerned,  while  the  population  per  nurse  is 
woefully  high  in  Pawtucket  and  Central  Falls  and  in  Cranston. 
There  is  no  community  of  2000  population  which  would  not  bene- 
fit by  the  service  of  a  trained  public  health  nurse  and  which  does 
not  need  such  a  nurse  in  order  that  preventable  disease  may  be 
avoided  and  needless  suffering  saved. 

In  the  first  communities  listed  in  Table  XXV  the  care  of  tubercu- 
losis cases  is  entrusted  to  special  nurses  who  devote  all,  or  most,  of 
their  time  to  this  task.  We  may  therefore  consider  the  work  of 
these  tuberculosis  nurses  first  of  all,  returning  later  to  the  anti- 
tuberculosis work  carried  out  by  the  generalized  nurses  working  in 
Cranston,  Westerly  and  the  smaller  communities. 

Taking  up,  first  of  all,  the  city  of  Providence,  sixteen  of  the  nurses 
included  in  Table  XXV  are  school  nurses  and  contagious  disease 
nurses  in  the  employ  of  the  Department  of  Health  while  fifty  are 
employed  by  the  Providence  District  Nursing  Association.  Of  these 
fifty  nurses,  seven  devote  themselves  wholly  to  tuberculosis.* 
They  are  well  trained  women  working  under  the  systematic  guidance 
of  a  thoroughly  qualified  and  able  supervisor.  Miss  Edgecomb,  and 
the  full  records  which  are  kept  furnish  evidence  of  admirable 
accomplishment.  The  nurses  of  the  D.  N.  A.  furnish  service  to  all 
the  clinics  of  the  city  and  problems  of  social  service  are  considered 
in  a  weekly  conference  with  representatives  of  the  Society  for  Or- 
ganizing Charity. 

Through  the  courtesy  of  Miss  Edgecomb  it  has  been  possible  to 
obtain  very  full  data  in  regard  to  the  work  of  the  D.  N.  A.  The 
chief  figures  so  far  as  admission  and  disposition  of  cases  is  concerned 
are  presented  in  Table  XXVI.  They  indicate  that  each  nurse 
cared  for  approximately  225  patients  during  1919;  and  that  6.6 
persons  per  1000  total  p(;pulation  came  under  the  care  of  the  tuber- 
culosis nurses.  The  tuberculosis  nurses  of  the  New  Haven  V.  N.  A. 
care  for  almost  exactly  the  same  proportion  of  the  population  (6.8 
per  1000);  but  each  nurse  has  an  average  of  only  159  cases  under 
her  care.  In  New  Haven,  however,  the  tuberculosis  nurses  care 
for  the  severely  ill  cases,  which  they  do  not  do  in  Providence. 


♦These  nurses  do  not   give  bedside  care  to  cases  which  are  severely  ill,  such  cases  taking  up 
about  half  the  time  of  one  additional  nurse. 

57 


TABLE  XXVI. 
General  Summary  of  the  Tuberculosis  Nursing  Service  of  the  Provi- 
dence DisTRisT  Nursing  Association. 
Admission 
1917  1918  1919 

Under  care,  Jan.  1  755  869  1022 

Admitted  during  year  419  494  551 

Total  1174  1363  1573 


1917  1918  1919 

Under  care,  Dec.  31*                742  909  1049 

In  sanatoria  Dec.  31t               127  113  162 

Discharged  non-tuberculous      32  45  54 

Dead                                            177  217  222 

Left  city  or  lost                          96  79  86 

Total                                    1174  1363  1573 


*Exclusive  of  cases  in  sanatoria  and  hospitals. 

tTotal   eases  in  sanatoria  and  hospitals  during  year:     1917,  237;  1918,  281;  1919,  348.     Total 

cases  which  had  at  some  time  received  hospital  and  sanatorium  care:     1917,  418;  1918,  629; 

1919,  577. 

The  type  of  cases  cared  for  is  indicated  in  a  general  way  in  Table 
XXVII. 

TABLE  XXVII. 

Classification  of  Cases. 

1917  1918  1919 

Positive  cases                             631  708  830 

Contact  cases                             296  349  375 

Suspicious  cases                         165  209  223 

Non-pulmonary  cases                  82  97  145 

Total  1174  1363  1573 

The  source  from  which  the  District  Nursing  Association  cases 
were  obtained  during  the  year  1919  are  indicated  in  Table  XXVIII. 


TABLE  XXVIII. 

Source  of  Cases, 

1919.* 

Positive  cases 

Contact 

suspicious  cases 

Physicians 

163 

72 

Clinics 

198 

140 

Sanatoria  or  Hospitals 

245 

Other  agencies 

108 

91 

Found  by  nurses 

116 

295 

Total 

830 

598 

*Pulmonary  cases  only. 

58 


From  this  table  it  appears  that  the  tuberculosis  nurses  are  doing 
excellent  work  in  the  discovery  of  new  cases  of  frank  or  suspicious 
tuberculosis.  They  have  themselves  discovered  almost  exactly 
half  of  all  the  contact  and  suspicious  cases  for  which  they  care,  and 
14  per  cent  of  the  definitely  positive  cases,  against  20  per  cent  re- 
ferred to  them  by  physicians,  24  per  cent  by  clinics,  and  30  per  cent 
by  sanatoria  and  hospitals.  This  showing  is  really  better  than  it 
seems,  since  the  sanatorium  and  hospital  group  of  cases  did  not 
really  originate  with  those  institutions,  but  in  most  cases  were  sent 
there  by  physicians,  clinics  or  public  health  nurses. 

It  will  be  noted  from  Table  XXVII  that  out  of  the  1428  pul- 
monary cases  cared  for  in  1919,  830  were  positive  cases  and  598 
contact,  or  suspicious  cases.  Of  the  830,  301  were  classed  as  in- 
cipient, 415  as  moderately  advanced,  and  114  as  far  advanced,  in- 
dicating that  on  the  whole  the  material  with  which  the  nurses  deal 
is  fairly  promising.  Conditions  here,  however,  might  well  be  im- 
proved. In  New  Haven,  out  of  266  new  cases  admitted  by  the 
V.  N.  A.  in  1919,  119  were  incipient  cases,  97  moderately  advanced 
and  only  50  far  advanced. 

The  next  problem  in  which  we  are  interested  is  the  nature  of  the 
care  which  is  given  to  the  patients  under  the  District  Nursing  Asso- 
ciation. Our  first  criterion  is,  of  course,  the  number  of  visits  paid; 
and  data  in  regard  to  this  point  are  presented  in  Table  XXIX  for 
the  three  years  1917-1919. 


TABLE  XXIX. 

Statistics  of 

VISITS 

PAID    BY 

Providence 

Tuberculosis 

Nurses. 

Visits  per  Patient 

1917 

1918 

1919 

No  visit  paid 

4 

7 

5 

1-2 

158 

233 

297 

3-4 

166 

257 

273 

5-6 

196 

247 

239 

7-9 

210 

218 

270 

10-12 

164 

183 

214 

13-18 

178 

158 

174 

19-24 

49 

31 

42 

25-35 

34 

20 

41 

Over  35 

15 

9 

18 

Total  cases 

1174 

1363 

1573 

Total  visits 

11944 

11128 

15359 

Average  visits  per  case 

10 

8 

10 

59 


The  visits  per  patient  indicated  in  this  table  appear  to  be  some- 
what low.  In  New  Haven,  the  Visiting  Nurse  Association  makes 
17  visits  per  patient  on  the  average.  In  New  Haven,  however,  as 
pointed  out  above,  each  nurse  has  only  159  patients  to  care  for  and 
severely  ill  bed  cases  are  nursed;  but  the  visits  made  per  year  by 
each  nurse  average  a  little  better  at  New  Haven,  2452,  as  against 
2194  in  Providence. 

The  results  of  treatment  are  a  little  less  satisfactory  than  at  New 
Haven,  14  per  cent  of  the  1919  patients  being  dead  at  the  end  of  the 
year  as  against  9  per  cent  in  New  Haven.  This  is  no  doubt  a  re- 
sult of  the  fact  that  14  per  cent  of  the  patients  nursed  in  New  Haven 
were  far  advanced  cases  against  19  per  cent  in  Providence.  Every- 
where the  results  of  the  treatment  of  tuberculosis  vary  directly 
with  the  stage  at  which  treatment  is  commenced. 

In  order  to  obtain  a  more  direct  measure  of  the  actual  results  ob- 
tained by  District  Nursing  Association,  I  obtained  through  the 
courtesy  of  Miss  Edgecomb  the  data  presented  in  Table  XXX. 
The  object  of  a  tuberculosis  nursing  service,  so  far  as  the  known 
case  is  concerned,  is  either  to  get  the  patient  into  a  sanatorium  or 
to  keep  the  patient  in  touch  with  a  clinic  and  to  render  such  home 
nursing  care  and  give  such  instruction  as  may  enable  him  to  recover 
in  the  home.  In  Table  XXX  are  presented  the  results  of  an  analysis 
of  448  random  cases  of  positive  pulmonary  tuberculosis,  under  ob- 
servation for  at  least  one  year,  classified  according  to  the  type  of 
treatment  given  and  its  results. 

TABLE  XXX. 

Analysis  of  Disposition  and  Results  in  448  Random  Cases  of  Pulmonary 

Tuberculosis   under   care   by   the    District    Nursing  Association. 

Prior  to  July  1,  1919. 

(Percentages) 

Cured    or 

Improved      Unimproved      Dead      Total 

A.  Admitted  to  hospital  or  sanato- 

rium and  kept  there  for  a  rea- 
sonably satisfactory  period.  53  19  11  83 

B.  Cared   for   at    home    under   ade- 

quate   sanitary    and    hygienic 

conditions.  9  2  1  12 

C.  Kept  at  home  without  adequate 

care.  2  2  2  6 


Total  64  23  14         101 

The  showing  made  by  the  District  Nursing  Association  in  this 
table  is  a  remarkable  one.     Eighty-three  per  cent  of  this  group  of 

6o 


cases  were  placed  in  sanatoria  or  hospitals  and  12  per  cent  were 
adequately  cared  for  in  the  home;  in  only  6  per  cent  of  the  488  cases 
was  there  a  failure  to  secure  satisfactory  treatment  in  one  way  or 
another.  The  result  is  that  but  14  per  cent  of  the  group  are  dead 
and  64  per  cent  are  classed  as  cured  or  improved.  The  Providence 
District  Nursing  Association  is  handling  a  large  group  of  cases  for 
the  size  of  its  staff;  it  is  detecting  many  new  cases  in  the  early  stages 
of  the  disease.  It  is  giving  adequate  and  intensive  nursing  care, 
and  it  is  achieving  marked  success  in  securing  sanatorium  treatment 
for  its  patients.  How  effectively  the  organization  works  is  well 
indicated  by  the  fact  that  of  889  patients  referred  to  the  District 
Nursing  Association  for  follow-up  work,  on  discharge  from  Wallum 
Lake  or  Providence  City  Hospital,  during  the  three  years  1917- 
1919,  only  37  cases  were  not  found;  114  were  at  once  admitted  to 
another  institution  than  the  one  they  had  left;  and  638  cases  were 
found  at  home  and  given  nursing  care. 

The  onh-  thing  one  could  wish  would  be  an  enlargement  of  the 
staff  of  tuberculosis  nurses,  so  that  the  volume  of  work  could  be 
multiplied.  From  what  we  know  of  the  actual  amount  of  uncared 
for  tuberculosis  in  every  community  it  is  certain  that  fifteen  tuber- 
culosis nurses  could  profitably  be  employed  in  Providence  instead 
of  seven;  in  New  Haven,  wuth  a  population  of  a  little  over  160,000, 
seven  nurses  under  the  Visiting  Nurse  Association  and  two  nurses 
under  the  Health  Department  devote  their  whole  time  to  tuberculo- 
sis cases.  It  must  be  remembered,  however,  that  even  under 
present  conditions  Providence  is  far  better  off  than  the  rest  of  the 
state, — or  than  most  American  cities. 

In  the  Pawtucket  and  Central  Falls  district  one  of  the  nine  nurses 
employed  by  the  Visiting  Nurse  Association  devotes  herself 
entirely  to  tuberculosis  work,  the  population  served  being  nearly 
100,000.  During  the  year,  April  1,  1919  to  April  1,  1920,  305  cases 
were  cared  for  and  3029  visits  made,  an  enormous  amount  of  work 
accomplished  by  one  nurse,  but  far  too  heavy  a  load  to  be  carried 
effectively.  It  is  not  surprising  that  67,  or  22  per  cent,  of  these  305 
patients  died  during  the  year  as  compared  with  14  per  cent  of  the 
patients  cared  for  in  Providence.  One  nurse  working  in  a  popula- 
tion of  100,000  people  can  only  give  care  to  the  most  advanced  cases 
and  cannot  possibly  find  time  for  the  more  fruitful  work  of  discover- 
ing the  early  and  favorable  cases.  Seventy-nine  per  cent  of  the 
patients  under  care  in  Pawtucket  on  May  28  were  positive  cases, 

6i 


against  53  per  cent  during  the  year  1919  in  Providence.  There  is 
obviously  a  very  great  need  for  several  more  tuberculosis  nurses  in 
this  district. 

In  Woonsocket  one  of  the  six  nurses  of  the  Public  Health  Nursing 
Association  has  devoted  herself  entirely  to  tuberculosis  since  Sep- 
tember 1,  1919;  prior  to  that  time  tuberculosis  cases  were  cared  for 
on  the  generalized  nursing  plan.  Again  the  population  of  over 
40,000  is  much  too  large  for  a  single  nurse,  though  the  discrepancy 
is  not  nearly  so  large  as  at  Pawtucket.  During  the  year  1919,  229 
tuberculosis  patients  were  treated,  of  whom  107  remained  under 
care  on  December  31,  53  were  discharged  to  hospital  or  sanatorium 
care,  29  were  dead,  24  were  discharged  well  or  improved  and  16 
were  discharged  for  other  causes.  Eighteen  hundred  and  sixty- 
three  visits  were  paid.  This  is  too  low  a  ratio,  but  in  general  the 
statistics  indicate  successful  results.  Only  13  per  cent  of  the  pa- 
tients treated  died  during  the  year;  a  remarkably  fortunate  result 
in  view  of  the  fact  that  of  106  cases  under  care  in  September,  1920, 
67  per  cent  were  positive  cases.  The  Woonsocket  nursing  staff 
deserves  very  special  success  for  its  efforts  to  keep  the  tuberculosis 
clinic  in  operation  in  the  face  of  disheartening  difficulties. 

The  only  other  nurse  who  gives  full  time  to  tuberculosis  work  is 
the  nurse  at  the  Pawtuxet  Valley  (Riverpoint)  Clinic,  who  serves 
chiefiy  the  town  of  West  Warwick  and  Coventry,  with  a  contribu- 
tory population  of  between  20,000  and  30,000  persons.  Here  we 
have  the  nearest  approach  to  an  adequate  service,  outside  of  Provi- 
dence. The  very  capable  nurse  at  this  center  cared  for  169  cases 
during  the  year  ending  July  1,  1920,  and  made  1775  visits,  an  ex- 
cellent ratio  for  a  rural  district.  Of  these  169  cases,  96  were  still 
under  care  July  1,  1920,  10  were  in  sanatoria  or  hospitals,  35  had 
been  discharged  and  28  were  dead. 

In  East  Providence  one  nurse  divides  her  time  between  tuber- 
culosis and  school  work.  During  the  year  ending  July  1,  1920,  she 
cared  for  70  tuberculosis  cases  and  made  420  visits,  far  too  low  a 
ratio.  Of  these,  36  were  still  under  care  on  July  1,12  were  in  sana- 
toria, 14  had  died,  6  had  moved  away  and  2  had  been  lost.  The 
death  rate,  20  per  cent,  is  high  and  it  seems  clear  that  more  intensive 
tuberculosis  work  is  needed  in  this  community. 

The  situation  as  regards  tuberculosis  nursing  in  Newport  is  most 
unusual.  The  city  has  a  school  nurse  and  an  infant  welfare  nurse 
and  a  Metropolitan  Life  Insurance  nurse;  and  externe  home  nursing 
service  is  rendered  by  two  pujiil  nurses  from  the  hospital  under  the 

62 


(direction  of  a  supervisor.  This  supervisor  under  an  arrangement 
with  the  city  herself  gives  nursing  care  to  advanced  indigent  cases  of 
tuberculosis  but  has  had  only  one  such  patient  in  the  last  six  months. 
The  general  task  of  detecting  and  supervising  early  cases,  which  is 
the  normal  function  of  a  public  health  nurse,  is  in  Newport  under- 
taken by  the  Secretary  of  the  local  Anti-Tuberculosis  Association, 
Miss  Mary  K.  Akerley.  Miss  Akerley  is  accomplishing  much 
valuable  work  but  the  most  efifectiv'e  instructive  work  in  the  home 
can  only  be  done  by  a  fully-trained  public  health  nurse.  The  lack 
of  a  clinic  and  the  lack  of  tuberculosis  nursing  service  are  no  doubt 
important  factors  in  the  meagre  reporting  of  tuberculosis  and  in  the 
relatively  low  hospitalization  for  the  city  of  Newport. 

The  rest  of  the  anti-tuberculosis  nursing  work  of  the  state  is  done 
as  part  of  the  generalized  public  health  nursing  service  in  the  cities 
and  towns  of  Harrington,  Bristol,  Burrillville,  Cranston,  East  Green- 
wich, Johnston,  Little  Compton,  Middletown,  North  Kingstown, 
North  Providence,  Smithfield,  South  Kingstown,  Tiverton,  War- 
ren, Warwick,  and  Westerly.  A  circular  letter  was  sent  to  the  pub- 
lic health  nurses  of  these  towns  asking  for  certain  data  in  regard 
to  their  tuberculosis  work  during  the  past  calendar  year  and  in 
every  case  the  information  was  most  courteously  and  promptly 
furnished ;  and  the  results  are  presented  in  Table  XXXI  below. 


TABLE  XXXI. 

Cases  Cared  for  by  Generalized  Nurses  in 

Sixteen  Rhode  Island  Towns. 


03    u 

o      a 

-.     ^.^     O 

c 

•B 

6 

> 

CS  >> 

Q 

OS   Ms- 

o 

3 

5 

s 

1-1 

Barrington 

14 

219 

7 

2 

1 

3 

1 

0 

Bristol 

29 

354 

7 

6 

6 

2 

8 

0 

Burrillville 

13 

476 

6 

5 

1 

1 

0 

0 

Cranston 

30 

211 

11 

8 

3 

6 

2 

0 

East  Greenwich 

5 

146 

3 

0 

2 

0 

0 

0 

Johnston 

16 

178 

13 

0 

0 

3 

0 

0 

Little  Compton 

3 

15 

1 

1 

0 

1 

0 

0 

Middletown 

3 

39 

2 

0 

1 

0 

0 

0 

North  Kingstown 

2 

75 

0 

0 

1 

0 

1 

0 

North  Providence 

22 

490 

6 

9 

5 

2 

0 

0 

Smithfield 

9 

164 

6 

2 

0 

1 

0 

0 

South  Kingstown 

11 

450 

4 

4 

0 

1 

2 

0 

Tiverton 

3 

186 

2 

1 

0 

0 

0 

0 

Warren 

9 

91 

1 

5 

3 

0 

0 

0 

Warwick 

18 

56 

2 

5 

1 

1 

1 

8 

Westerly- 

6 

13 

2 

2 

2 

0 

0 

0 

Total 


193     3163 


73 


50 


26 


21 


15 


63 


The  death  rate  for  this  group  of  cases  as  a  whole  is  high  (25  per 
cent)  and  the  wide  variations  between  the  ratio  of  visits  per  case 
indicate  startHng  divergence  of  practise.  It  can  hardly  be  that 
tuberculosis  cases  in  North  Kingstown  and  South  Kingstown  really 
require  40  visits  a  year;  and  those  in  Warwick  and  Westerly  must 
certainly  need  more  than  the  two  or  three  visits  they  receive. 

As  a  matter  of  fact  these  data  simply  indicate  that  in  some  towns 
the  nurses  are  overworked  while  in  others  they  have  free  time  on 
their  hands.  The  work  of  the  public  health  nurse  in  a  small  com- 
munity would  benefit  greatly  by  expert  supervision;  and  the  plan 
of  the  State  Board  of  Health  to  obtain  appropriations  for  a  Division 
of  Public  Health  Nursing  is  a  most  commendable  one.  A  qualified 
Director  of  Public  Health  Nursing,  such  as  many  states  now  pos- 
sess, would  be  of  the  greatest  service  in  developing  and  standardiz- 
ing public  health  nursing  in  Rhode  Island.  The  project  deserves  the 
earnest  support  of  all  who  are  interested  in  the  tuberculosis  problem. 

Aside  from  the  aberrancies  manifested  in  a  few  of  the  smaller 
towns  the  quality  of  the  service  rendered  by  the  public  health 
nurses  of  Rhode  Island  seems  to  be  admirable.  It  is  in  quantity 
that  it  is  deficient;  and  the  particular  weak  points  are  brought  out 
by  the  statistics  presented  in  Table  XXXII. 

It  is  apparent  that  the  Pawtuxet  Valley  region  is  better  served 
than  any  other  section  of  the  state.  The  figures  are  a  little  more 
favorable  than  they  should  be,  for  we  have  used  only  the  popula- 
tions of  West  Warwick  and  Coventry  in  computing  our  ratios  and 
the  nurse  at  Riverpoint  cares  for  a  few  cases  in  adjoining  parts  of 
Scituate  and  Cranston.  Providence  comes  next,  with  65  nursing 
visits  to  tuberculosis  cases  per  1000  population  per  year.  Woon- 
socket  stands  next,  while  Pawtucket,  East  Providence  and  the  small 
towns  served  by  generalized  nurse  service  are  notably  deficient. 

TABLE  XXXII. 
Relative  Extent  of  Tuberculosis  Nursing  Service  for  Various  Areas 

IN  Rhode  Island. 
Tuberculosis  Patients 


Given  Nursing 

Care 

Visits  to  Tuberculosis 

Visits 

per 

1000  Popul 

ation 

Patients 

i  per 

1000 

Per 

per 

Year 

Population  per  year 

Case 

Providence 

7 

65 

10 

Pawtuciiet,  Central  Falls, 

Cumberland 

3 

30 

10 

Woonsocket 

5 

43 

8 

West  Warwick,  Coventry 

8 

85 

11 

East  Providence 

3 

19 

6 

Generalized   Nurses  in   16 

small  towns 

2 

26 

16 

State  as  a  whole 

4 

42 

10 

64 


In  Xew  Haven  the  nine  tuberculosis  nurses  (seven  under  the 
Visiting  Nurse  Association  and  two  under  the  Board  of  Health) 
care  for  eight  patients  and  make  127  visits  per  year  per  1000  popu- 
lation, an  average  of  16  visits  per  case.  Rhode  Island  needs  more 
tuberculosis  nursing  all  along  the  line;  and,  particularly,  it  is  clear 
that  the  State  Board  of  Health,  the  Rhode  Island  Tuberculosis 
Association  and  other  agencies  should  do  everything  possible  to 
stimulate  the  development  of  public  health  nursing  in  Newport,  in 
Cranston  (where  only  7  nursing  visits  to  tuberculosis  cases  are 
made  per  1000  population),  in  East  Providence,  and  in  the  Paw- 
tucket  region. 

In  order  to  complete  the  picture  of  public  health  nursing  in  Rhode 
Island  brief  mention  must  be  made  of  the  activities  of  nurses  em- 
ployed by  the  larger  industrial  plants  of  the  state.  The  names  of 
19  such  nurses  were  courteously  furnished  to  us  by  the  officers  of 
the  Providence  District  Nursing  Association  and  a  letter  was  writ- 
ten to  each  nurse  to  ask  if  she  did  any  work  in  the  homes  of  tuber- 
culosis patients,  either  nursing  care  or  social  service.  Sixteen  replies 
were  received  to  this  letter.  In  eleven  cases  it  was  stated  that  no 
nursing  care  was  given  in  the  home,  although  in  most  instances  the 
writer  made  clear  that  cases  of  tuberculosis  occurring  in  the  factory 
are  followed  up  to  some  extent  and  placed  in  the  hands  of  com- 
munity nursing  or  social  service  agencies.  Of  the  eleven  plants 
which  give  no  home  nursing  service  seven  are  located  in  Providence 
and  three  in  Pawtucket.  On  the  other  hand  one  firm  in  Providence, 
one  in  Bristol,  one  in  Lincoln,  one  in  Cumberland  and  one  in  Coven- 
try, report  that  home  nursing  care  is  given  to  cases  of  tuberculosis, 
a  highly  commendable  practice  for  an  industry  located  in  a  rural 
section.  Four  of  these  five  nurses  report  a  total  of  nine  cases  of 
tuberculosis  cared  for  during  the  past  year;  so  that  the  influence 
of  this  factor  upon  the  general  statistics  cited  above  is  not  an  im- 
portant one.  In  passing  it  may  be  noted  that  the  work  of  the  in- 
dustrial nurses  in  Rhode  Island  would  be  far  more  effective  if  cor- 
related with  adequate  medical  service.  I  am  informed  that  there  is 
not  a  single  full-time  industrial  physician  in  the  state  of  Rhode 
Island  and  that  in  many  instances  the  factory  nurses  for  lack  of 
medical  direction  are  tempted  to  assume  responsibilities  which 
properly  belong  to  the  medical  profession  alone.     The  pro\ision, 

.65 


in  connection  with  the  larger  industries,  of  plant  hospitals,  wherever 
possible  with  full-time  medical  service,  would  prove  a  powerful 
weapon  in  the  anti-tuberculosis  campaign. 


VII.     THE    PART    PLAYED    BY    VOLUNTARY    ASSOCIA- 
TIONS   IN    THE    ANTI-TUBERCULOSIS    CAMPAIGN. 

The  view  has  been  emphasized  throughout  this  report  that  more 
definite  and  vigorous  participation  of  official  health  organizations 
is  the  greatest  need  of  the  anti-tuberculosis  movement  at  the  present 
time.  On  the  other  hand,  it  is  equally  true  that  there  are  many 
things  which  can  best  be  accomplished  by  private  initiative:  and 
the  volunatry  anti-tuberculosis  association  must  always  play  an 
important  and  essential  part  in  this  campaign.  Rhode  Island  is 
fortunate  in  possessing  a  number  of  organizations  of  this  type,  and 
particularly  a  strong  state  association  and  a  strong  tuberculosis 
league  for  the  city  of  Providence. 

The  Rhode  Island  Tuberculosis  Association,  under  whose  au- 
spices this  survey  has  been  conducted,  has  been  in  operation  for  over 
thirteen  years.  It  has  an  excellent  constitution,  providing  for  full 
representation  in  its  directorate  of  various  public  and  semi-public 
agencies,  such  as  the  State  Board  of  Health,  the  State  Sanatorium, 
the  various  hospitals,  the  local  health  department,  and  anti-tuber- 
culosis and  district  nursing  associations, — with  fifteen  members  at 
large.  The  Executive  Committee  is,  however,  a  rather  small  one, 
including  only  three  members,  besides  the  President,  First  Vice- 
President  and  Secretary.  It  would  seem  best  to  add  at  least  two 
more  members  to  this  committee  and,  in  particular,  to  place  upon 
it  one  or  more  public  spirited  and  influential  women,  in  order  that 
the  potential  influence  of  the  newly  enfranchised  half  of  the  popu- 
lation may  be  fully  utilized.  The  budget  of  the  association  during 
the  past  year  amounted  to  $7100,  derived  chiefly  from  the  sale  of 
Red  Cross  seals.  The  success  of  the  association  is  in  large  measure 
due  to  the  devoted  and  effective  service  of  its  Executive  Secretary, 
Mr.  Willis  E.  Chandler. 

The  activ^ities  of  an  organization  of  this  type  may  conveniently 
be  classed  under  the  five  heads  of  Research,  Education,  Legislative 
Propaganda,  Organization  and  Direct  Service.  The  present  re- 
port is  the  most  recent  evidence  of  the  interest  of  the  Association 

66 


along  the  first  of  these  Hnes;  and  the  Association  Hke  the  Providence 
League  has  made  important  contributions  in  the  past  to  the  study 
of  the  problems  of  housing,  which  bear  so  directly  upon  those  of 
tuberculosis.  Mr.  Chandler  served  as  secretary  of  the  Committee 
on  Improved  Housing  in  Providence,  to  which  Mr.  John  Ihlder  made 
his  admirable  report  on  The  Houses  of  Providence,  in  1916.  The 
attempt  to  secure  the  legislation  contemplated  in  this  report  un- 
fortunately failed,  but  should  be  renewed  when  economic  conditions 
make  its  prosecution  possible. 

From  the  standpoint  of  publicity,  the  state  association  has  de- 
voted itself  particularly  to  the  advertisement  of  the  value  of  clinic 
and  sanatorium  treatment  and  to  educational  work  in  the  schools. 
A  very  effective  circular  has  been  prepared,  describing  the  facilities 
at  Wallum  Lake  and  information  in  regard  to  the  Providence  clinics 
is  presented  through  paid  advertisements  in  the  leading  English 
and  foreign-language  newspapers.  For  reaching  the  school  chil- 
dren of  the  state  the  admirable  machinery  of  the  Modern  Health 
Crusade  is  being  effectively  utilized.  Both  these  lines  of  activity 
are  of  the  greatest  value  and  should  be  continued  and  extended.  In 
connection  with  the  Health  Crusade  it  would  be  well  to  develop  a 
campaign  along  the  lines  laid  down  by  the  Child  Health  Organiza- 
tion of  America  for  the  monthly  weighing  and  measuring  of  school 
children,  with  the  development  of  nutrition  clinics,  and  of  effectiv'e 
general  education  in  dietary  hygiene.  A  beginning  of  activities 
along  this  line  was  made  during  the  first  half  of  1920  by  Dr.  Ellen 
Stone,  Director  of  Child  Hygiene  in  the  City  Department  of  Health, 
and  by  one  of  the  school  nurses.  Similar  work  was  done  last  year 
in  a  primary  school  by  a  worker  representing  the  Providence  House- 
\vi\es'  League.  Much  more  should,  however,  be  accomplished 
along  these  lines  in  all  the  cities  of  the  state.  Malnutrition  is  cer- 
tainly one  of  the  most  important  contributory  causes  to  tuberculo- 
sis; and  the  "scale  in  every  school"  movement  is  perhaps  the  best 
method  of  obtaining  a  hearing  for  the  lessons  of  dietary  hygiene. 

The  state  association  has,  in  the  past,  played  an  important  part 
in  securing  the  legislation  which  provided  the  state  sanatorium  at 
Wallum  Lak(?,  in  obtaining  the  present  legislation  in  regard  to  the 
isolation  of  tuberculosis,  and  in  securing  local  action  by  towns  and 
cities  in  favor  of  fresh  air  school  rooms.  Of  the  latter,  there  are 
now  five  in  operation  in  Providence,  accommodating  100  children 
in  all,  and  others  in  Pawtucket  and  Newport.     The  most  immediate 

67 


problems  for  the  association  in  the  legislative  field  would  appear  to 
be  the  securing  of  the  appointment  of  a  state  Director  of  Tuberculo- 
sis under  the  State  Board  of  Health  and  the  obtaining  of  appropria- 
tions for  improving  the  road  between  Pascoag  and  Wallum  Lake. 

In  the  field  of  organization,  the  Rhode  Island  Tuberculosis  Asso- 
ciation has  done  yeoman  service  in  the  development  of  local  anti- 
tuberculosis associations  and  of  district  nursing  service  and  has 
made  gratifying  progress  in  standardizing  nursing  records  and  pro- 
cedures in  the  smaller  communities.  The  following  24  different 
local  anti-tuberculosis  associations,  health  leagues  or  district  nurs- 
ing associations  within  the  State  of  Rhode  Island  are  at  present 
affiliated  with  the  State  Association : 

Harrington  District  Nursing  Association 

Nursing  Committee  of  the  Bristol  Fortnightly  Club 

Burrillville  Anti-Tuberculosis  Association 

Cranston  Anti-Tuberculosis  Association 

Visiting  Nurse  and  Anti-Tuberculosis  Association  of  East  Green- 
wich 

East  Providence  District  Nursing  Association 

Glocester  Anti-Tuberculosis  Association 

Johnston  District  Nursing  Association 

Newport  Association  for  the  Relief  and  Prevention  of  Tubercu- 
losis 

New  Shoreham  Anti-Tuberculosis  Committee 

Visiting  Nurse  and  Anti-Tuberculosis  Association  of  North  Kings- 
town 

North  Providence  District  Nursing  and  Anti-Tuberculosis  Asso- 
ciation 

Pawtucket  Chapter  of  the  American  Red  Cross 

Visiting  Nurse  and  Anti-Tuberculosis  Association  of  the  Paw- 
tuxet  Valley 

Providence  District  Nursing  Association 

Providence  Tuberculosis  League 

Smithfield  Public  Health  Association 

South  Kingstown  Public  Health  League 

Warren  District  Nursing  Association 

Warwick  Health  League 

Westerly  Committee  on  the  Prevention  of  Tuberculosis 

Woonsocket  Public  Health  Nursing  Association 

68 


The  need  for  additional  nursing  service  is  still  very  great  and  every 
effort  should  be  devoted  to  the  increase  of  existing  staffs  (particu- 
larly in  Cranston  and  Pawtucket),  and  to  the  building  up  of  new- 
nursing  organizations  (particularly  in  Newport  County). 

Among  other  lines  of  direct  service  the  state  association  played 
a  large  part  in  the  early  development  of  the  Preventorium  at  Hoxsie 
and  during  the  war  did  an  admirable  piece  of  work  in  the  supervision 
of  drafted  men  rejected  for  tuberculosis,  and  service  men  invalided 
for  this  cause.  For  the  future  it  would  seem,  in  view  of  the  specially 
close  relation  existing  between  this  association  and  the  state  sana- 
torium, that  the  provision  of  a  social  service  worker  at  the  sana- 
torium, and  the  development  of  convenient  transportation  facilities 
between  Providence  and  Wallum  Lake,  would  be  natural  and  de- 
sirable activities  of  the  association. 

The  second  voluntary  organization,  of  major  importance,  is  the 
Providence  Tuberculosis  League,*  which  was  organized  in  1905  as 
the  Tuberculosis  Committee  of  the  Society  for  Organizing  Charity. 
It  is  governed  by  a  board  of  fifteen  directors,  with  an  executive  com- 
mittee of  seven.  As  in  the  case  of  the  state  association  the  ex- 
ecutive committee  of  this  organization  might  be  strengthened  by 
the  inclusion  of  one  or  more  public  spirited  lay  women.  The  budget 
of  the  league  in  1920  amounted  to  825,000,  derived  partly  from  its 
quota  of  the  Red  Cross  Christmas  seal  sale,  and  partly  from  a  spe- 
cial annual  appeal  for  funds  for  the  Preventorium. 

With  the  appointment  of  Dr.  Elliott  Washburn  as  Executive 
Secretary,  early  in  the  present  year,  an  admirable  program  of  ex- 
pansion has  been  planned  in  the  investigative  field.  The  three 
main  projects  which  are  contemplated  are  (a)  an  intensive  health 
survey  of  a  selected  district  in  the  city  of  Providence,  (b)  a  study  of 
industrial  problems  of  the  city  with  special  reference  to  the  factors 
tending  to  produce  industrial  tuberculosis  and  to  the  possibilities 
of  combating  tuberculosis  through  organized  industrial  medical  and 
nursing  service,  and  (c)  a  study  of  the  possibilities  of  occupational 
therapy,  and  of  the  feasibility  of  developing  facilities  for  the  self- 
support  of  arrested  cases  of  tuberculosis.  The  last  tw^o  of  these 
problems  are  of  supreme  importance  in  the  development  of  our 
future  campaign ;  and  the  League  has  shown  both  courage  and  vision 
in  placing  them  in  the  forefront  of  its  program.     The  relation  of 


♦References  to    the  League  in  the  following  discussion  includes  the  work  of  its  precursor,  the 
Tuberculosis  Committee  of  the  Providence  Society  for  Organizing  Charity. 

69 


tuberculosis  to  industry  (and  particularly  to  the  hazard  of  industrial 
dusts)  is  one  of  the  most  significant  and  one  of  the  most  neglected 
phases  of  the  etiology  of  this  disease;  the  betterment  of  sanitary 
conditions  in  the  factory  and  the  provision  of  adequate  systems  of 
medical  examination  for  industrial  workers  should  accomplish 
notable  results  in  the  prevention  of  tuberculosis.  For  the  per- 
manent cure  of  those  already  affected  with  the  disease,  the  provision 
of  industrial  colonies,  model  factories  or  model  tenements,  in  which 
arrested  cases  can  become,  so  far  as  possible  self-supporting,  and 
yet  remain  under  favorable  environmental  conditions,  is  an  absolute 
essential.  If  the  Providence  Tuberculosis  League  can  carry  these 
two  investigations  to  a  successful  conclusion  it  will  render  a  great 
service  to  the  cause  of  public  health  throughout  the  country,  as 
well  as  in  Rhode  Island.  The  after  care  of  arrested  cases  is  so  large 
a  problem  and  one  of  such  paramount  importance,  that  it  might 
well  be  attacked  by  a  joint  committee  representing  both  state  and 
city  associations. 

In  the  field  of  education,  the  League  has  followed  much  the  same 
lines  as  the  State  Association,  having  held  numerous  local  exhibits,  and 
having  made  a  beginning  with  the  Modern  Health  Crusade  move- 
ment in  the  schools.  The  education  of  the  school  child  in  the  principles 
of  hygiene  is  absolutely  fundamental  to  the  whole  future  progress 
of  public  work.  The  Health  Crusade  activities  should  be  steadily 
extended;  and  as  suggested  above  it  would  be  wise  to  lay  particu- 
lar stress  upon  the  problem  of  dietary  hygiene.  The  development 
of  the  Health  Crusade  movement  in  Rhode  Island  has  been  un- 
fortunately hampered  by  the  fact  that  certain  educational  officials 
are  not  in  sympathy  with  some  of  its  essential  features. 

The  legislative  work  of  the  League  has  been  mainly  directed  to- 
ward the  securing  of  open-air  schools,  the  strengthening  of  the  tuber- 
culosis work  of  the  municipal  health  departments  and  the  support 
of  the  state  campaign  for  isolation  legislation  and  for  the  main- 
tenance of  the  sanatorium  at  Wallum  Lake.  If  the  conclusions  of 
this  report  are  approved,  the  most  immediate  political  task  of  the 
League  is  the  securing  of  appropriations  from  the  city  government 
for  the  creation  of  a  Division  of  Tuberculosis  in  the  municipal  de- 
partment of  health. 

In  the  field  of  organization,  the  League  has  played  an  indispen- 
sable part  in  the  development  of  clinic  and  nursing  service  for  the 
city  of  Providence,  as  well  as  in  the  establishment  of  the  Preven- 

70 


torium.  The  first  evening  clinic  for  tuberculosis  in  the  city  was 
organized  by  the  League  in  1911  (later  transferred  to  the  City  Hos- 
pital) ;  and  the  Fresh  Air  School,  opened  on  Meeting  Street  in  1908, 
was  the  first  fresh  air  school  in  America. 

Direct  service  can  not  be  sharply  separated  from  organization, 
since  several  of  the  Providence  clinics,  as  well  as  the  Day  Camp, 
were  actually  operated  by  the  League,  and  from  1907  to  1910  it 
paid  the  expenses  of  the  tuberculosis  nursing  staff.  The  chief 
direct  work  of  the  League  has,  however,  been  the  maintenance  of 
the  Preventorium,  and  summer  outings  which  have  be^  discussed 
in  an  earlier  section. 

A  new  project,  of  the  greatest  importance,  was  initiated  on  Octo- 
ber 11,  when  a  letter  was  sent  to  400  physicians  of  the  city  offering 
the  free  service  of  the  executive  secretary  as  Tuberculosis  Con- 
sultant. Examinations  will  be  made  at  the  office  of  the  League, 
at  the  office  of  the  physician  or  at  the  home  of  the  patient.  Dr. 
Washburn  is  admirably  qualified  for  this  work  and  the  utilization  of 
this  consultation  service  by  the  local  medical  profession  will  make 
possible  a  notable  advance  in  the  conduct  of  the  entire  campaiga 
against  tuberculosis  in  Providence. 


VIIL     SUMMARY  OF  CONCLUSIONS  AND  RECOMMEN- 
DATIONS. 

The  present  survey  of  the  tuberculosis  situation  in  Rhode  Island 
has  been  conducted  on  the  assumption  that  the  mortality  from 
tuberculosis  is  in  large  measure  controllable,  by  definite  and  specific 
administrative,  and  medical,  and  nursing  procedures.  Both  theo- 
retical knowledge  and  practical  experience  indicates  that  the  sever- 
ity of  community  infection  can  be  reduced  by  the  pasteurization  of 
milk  and  the  control  of  open  cases  among  human  beings  and  that 
the  development  of  the  disease  process  can  be  prevented  or  arrested 
by  the  building  up  of  individual  resistance,  the  latter  line  of  attack 
being  on  the  whole  the  more  promising  of  large  results.  The  rela- 
tively slow  progress  which  was  made  in  the  control  of  this  disease 
l)etween  1910  and  1918  is  more  reasonably  attributable  to  the  im- 
perfection of  official  organization  and  the  slackening  of  public  in- 
terest in  the  problem  than  to  any  inherent  defects  in  the  anti- 
tuberculosis   program     itself.     The     improvement    in    social    and 

71 


economic  conditions  during  the  past  two  years  has  led  to  gratify- 
ing reduction,  in  the  tuberculosis  death  rate  throughout  the  United 
States;  but  this  fortuitous  gain  should  be  only  an  encouragement 
to  a  renewed  and  purposeful  attempt  to  hold  what  has  been  won 
and  to  accomplish  further  victories. 

Tuberculosis  still  remains  one  of  the  two  leading  causes  of  death 
in  the  state  of  Rhode  Island,  heart  disease  alone  claiming  an  equal 
number  of  victims;  and  each  of  these  causes  ordinarily  accounts  for 
over  10  per  cent  of  all  the  deaths  which  occur  within  the  state.  The 
tuberculosis  death  rate  in  Rhode  Island  is  abnormally  high,  as  com- 
pared with  the  Registration  Area  of  the  United  States  as  a  whole 
or  with  such  a  neighboring  state  as  Connecticut;  and  the  excess 
would  amount  to  about  15  per  cent,  even  if  the  1920  census  of 
Rhode  Island  were  assumed  to  be  incorrect  and  the  population  of 
the  state  were  estimated  on  the  basis  of  the  1910  and  1915  censuses 
alone.  The  high  death  rate  is  undoubtedly  in  large  part  attribut- 
able to  the  intensely  urban  and  industrial  conditions  of  the  state 
and  to  its  large  foreign  population ;  but  whatever  the  cause  may  be, 
the  problem  is  here. 

A  study  of  the  mortality  figures  for  different  sections  of  the  state 
shows  that  Providence  has  by  far  the  highest  death  rate,  196  deaths 
from  tuberculosis  of  all  forms  per  100,000  population  for  the  de- 
cennium  1910-1919.  Woonsocket  stands  next  with  a  rate  of  173, 
Central  Falls  third  with  a  rate  of  165  and  Pawtucket  fourth  with 
a  rate  of  158.  All  these  figures  are  extremely  high  and,  except  in 
the  case  of  Pawtucket,  there  has  been  no  appreciable  improvement 
in  the  last  half  of  the  decennium  as  compared  with  the  first.  A 
comparison  between  the  Providence  rates  and  those  recorded  for 
other  large  eastern  cities  shows  that  Providence  sufTered  far  more 
heavily  than  New  Haven,  Rochester,  or  Syracuse  in  the  quinquen- 
nium 1910-1914,  but  was  exceeded  at  that  time  by  New  York. 
For  the  quinquennium  1915-1919,  Providence  shows  no  reduction, 
while  all  the  other  cities  have  materially  decreased  their  rates,  that 
for  Syracuse  being  only  105,  and  even  that  for  New  York  being  172, 
as  compared  with  199  for  Providence.  It  seems  evident  that  Paw- 
tucket, Central  Falls,  Woonsocket,  and  particularly  Providence, 
face  a  tuberculosis  problem  of  unusual  magnitude,  a  problem  which 
is  not  at  present  in  the  way  of  being  solved. 

Newport,  Cranston  and  the  smaller  towns  of  the  state  show  ma- 
terially lower  tuberculosis  death  rates,  (Newport,  132;  Cranston,  96; 

72 


small  towns,  137).  Even  here,  however,  the  tuberculosis  menace 
is  a  very  real  one  since  any  disease  which  kills  one  person  out  of 
every  thousand  every  year  is  a  serious  problem.  The  fact  that  the 
mortality  in  these  communities  is  relatively  low  is  due  to  favor- 
able economic  conditions,  not  to  specific  anti-tuberculosis  machinery ; 
for  it  is  precisely  in  these  cities  and  towns  that  clinic  and  nursing 
service  has  been  least  developed.  It  is  natural,  but  not  judicious, 
to  accept  the  fact  that  one's  neighbors  are  even  worse  off,  as  an  ex- 
cuse for  inertia  in  the  betterment  of  one's  own  position. 

Turning  now  to  the  machinery  for  the  control  of  tuberculosis  in 
Rhode  Island,  it  appears  that  here,  as  in  many  American  com- 
munities, the  official  guardians  of  the  public  health, — the  state  and 
municipal  health  departments, — have  taken  but  little  direct  part 
in  the  campaign  against  the  most  serious  of  all  communicable  dis- 
eases. Reporting  of  cases  of  tuberculosis  was  first  required  in  the  city 
of  Providence  in  1905  and  a  state  reporting  law  was  passed  in  1909. 
The  system  of  reporting  to  the  State  Board  of  Health  would  be  a 
most  undesirable  one  if  it  led,  as  was  at  first  the  case,  to  a  complete 
cessation  of  local  activity.  At  present  transcripts  of  all  reports  are 
promptly  forwarded  to  local  authorities.  The  enforcement  of  the 
reporting  law  is,  however,  lamentably  defective.  The  cases  re- 
ported per  year  amount,  for  the  state  as  a  whole,  to  about  85  per 
cent  of  the  actual  deaths,  while  for  Pawtucket  and  Central  Falls 
they  rise  to  102-103  per  cent,  and  in  Newport  they  fall  to  54  per 
cent  of  the  actual  deaths.  Massachusetts  obtains  reports  of  about 
two  cases  for  every  death  and  special  surveys  indicate  that  in  Rhode 
Island,  as  elsewhere,  there  really  exist  about  nine  cases  to  each 
death.  We  may  fairly  assume  that  some  6000  cases  of  tuberculosis 
exist  in  Rhode  Island,  of  which  not  much  over  1000  arc  known  to 
the  authorities.  A  better  enforcement  of  the  reporting  law  is  cer- 
tainly one  of  the  first  desiderata  in  the  anti-tuberculosis  campaign. 

The  prompt  reporting  of  cases  of  tuberculosis  is  primarily  im- 
portant so  that  the  affected  individuals  may  be  brought  into  contact 
with  the  opportunities  for  clinic  and  sanatorium  and  nursing  ser- 
vice. In  the  vast  majority  of  cases  the  danger  of  infection  can  be 
controlled  without  rigorous  measures  of  isolation.  Legal  machinery 
must,  however,  be  provided  for  restraining  the  exceptional  wilfully 
careless  consumptive.  The  State  Board  of  Health  has  the  power  to 
promulgate  regulations  to  this  end;  and  it  seems  important  that 
more  definite  and  specific  rules  in  regard  to  the  isolation  of  the  care- 

73 


less  consumptive  should  be  formulated,  along  the  general  lines  laid 
down  in  the  sanitary  codes  of  Connecticut  and  New  York. 

Aside  from  the  provision  of  laboratory  diagnosis,  and  the  keep- 
ing of  a  register  of  cases,  by  the  State  Board  of  Health  and  by  the 
City  Health  Department  of  Providence,  neither  state  nor  local  au- 
thorities are  at  present  taking  any  active  part  in  the  anti-tuberculo- 
sis campaign.  The  most  important  step  which  can  be  taken  in 
developing  this  campaign  would  seem  to  be  the  organization,  under 
the  State  Board  of  Health,  and  under  the  Providence  Health  De- 
partment, of  Divisions  of  Tuberculosis,  each  under  the  charge  of  a 
medical  director,  expert  in  the  diagnosis  and  control  of  this  disease. 
Properly  qualified  men  in  these  positions  could  serve  as  the  respon- 
sible leaders  of  the  anti-tuberculosis  movement,  in  the  state  outside 
of  Providence  and  in  Providence  itself,  securing  the  enforcement  of 
legislation  for  reporting  and  isolation,  developing,  supervising,  and 
when  necessary  serving  local  clinics,  co-ordinating  nursing  and  social 
service,  and,  outside  the  city  of  Providence,  aiding  local  physicians 
through  a  consultation  service.  Steps  for  securing  the  appoint- 
ment of  such  official  leaders  of  anti-tuberculosis  work  in  state  and 
city  are  strongly  recommended  for  the  consideration  of  all  who  are 
interested  in  the  campaign  against  tuberculosis.  It  is  also  highly  de- 
sirable that  ordinances,  requiring  the  pasteurization  of  all  milk  not 
of  certified  grade  should  be  passed  in  the  leading  cities  of  the  state. 

In  the  everyday  conduct  of  anti-tuberculosis  work  the  clinic  for 
diagnosis  and  the  treatment  of  ambulant  cases  is  a  primary  essen- 
tial. Rhode  Island  has  at  present  thirteen  weekly  clinics  of  this 
type,  eight  in  Providence,  two  in  Pawtucket,  and  one  each  in  Woon- 
socket,  Riverpoint  and  East  Providence.  The  best  measure  of  the 
quantitative  adequacy  of  clinic  service  is  perhaps  the  number  of 
visits  paid  to  clinics  per  month  per  100,000  population.  From  this 
standpoint  Providence  and  the  Pawtuxet  Valley  district  (River- 
point  clinic)  make  the  best  showing,  with  91  and  95  visits  per  month 
per  100,000  population.  Even  this  ratio  is  low  compared  with  the 
corresponding  figure  for  New  York  City  (173);  while  Pawtucket 
and  Woonsocket  show  up  very  badly,  with  figures  of  45  and  30, 
respectively.  Of  the  cases  treated  at  the  Providence  clinics  (ex- 
cluding those  pronounced  non-tuberculous)  about  one-third  are 
placed  in  sanatoria  against  only  one-sixth  at  Woonsocket.  It  ap- 
pears that  the  number  of  new  patients  coming  to  the  clinics  is  fairly 
satisfactory  but  that  the  clinics  fail  to  hold  them.     In  New  York 

74 


City  we  find  an  average  of  6.0  visits  for  each  new  clinic  patient,  while 
the  best  of  the  Providence  clinics  show  less  than  4.0  and  the  Paw- 
tucket  and  Woonsocket  clinics  fall,  respectively,  to  1.8  and  2.0 
visits  per  new  patient.  A  record  such  as  those  last  cited  indicates 
that  the  clinic  organization  is  functioning  most  inefficiently;  and  the 
obvious  reason  is  to  be  found  in  a  more  or  less  half-hearted  voluntary 
medical  service  on  the  part  of  busy  practitioners  who  are  not  special- 
ists in  tuberculosis.  The  clinic  at  Riverpoint  is  admirable  and 
those  in  Providence  are  well  organized,  although  susceptible  of  con- 
siderable improvement.  In  the  other  large  cities,  the  service  ren- 
dered can  not  possibly  be  considered  adequate.  The  entire  southern 
half  of  the  state,  the  northwestern  quarter  of  the  state  and  the 
county  of  Newport,  including  nearly  a  third  of  the  population  of 
the  state,  are  without  organized  tuberculosis  clinic  facilities  of  any 
kind. 

It  seems  clear  that  the  opportunity  for  service  on  the  part  of  a 
State  Director  of  Tuberculosis  would  be  an  almost  unlimited  one  in 
this  particular  field.  A  tactful  leader  could  secure  the  reorganiza- 
tion of  the  Pawtucket  and  Woonsocket  clinics  on  an  effective  basis, 
could  develop  new  clinics  in  Newport  and  perhaps  in  Cranston, 
Warwick  and  Bristol,  and  coulcj  provide  periodic  clinic  service  in 
the  smaller  rural  communities. 

Even  in  Providence,  itself,  it  seems  probable  that  the  highest 
efficiency  of  tuberculosis  clinics  can  only  be  realized  in  the  long  run 
by  the  gradual  development  of  a  paid  medical  clinic  staff,  for  which 
the  City  Hospital  administration  offers  promising  facilities.  The 
records  at  all  the  clinics  should  be  reorganized  on  the  plan  used  in 
New  York  City  so  that  it  may  be  possible  to  determine  at  the  end 
of  each  month  how  many  patients  have  been  admitted  and  at  what 
stage  in  the  disease  process,  how  many  have  been  discharged  and 
for  what  reasons  and  in  what  condition.  The  provision  of  domicil- 
iary visits  for  those  cases  which  require  it  should  also  form  a  part 
of  a  comprehensive  plan  of  tuberculosis  control. 

Passing  to  the  problem  of  institutional  treatment,  Rhode  Island 
is  fortunate  in  possessing  a  well  equipped  and  well  managed  state 
sanatorium  at  Wallum  Lake  with  170  beds  for  sanatorium  cases, 
153  for  advanced  cases  and  40  for  children.  In  addition  the  Provi- 
dence City  Hospital  provides  beds  for  60  patients,  St.  Joseph's  Hos- 
pital Annex  at  Hillsgrove  for  70  patients  and  the  tuberculosis  wards 
at  the  State  Almshouse  and  Hospital  in  Cranston  for  46  patients, — 

75 


all  these  last  institutions  dealing  with  advanced  cases.  The  Pre- 
ventorium at  Hoxsie  (maintained  by  the  Providence  Tuberculosis 
League)  accommodates  40  children  in  winter  and  50  in  summer, 
while  the  Crawford  Allen  Branch  of  the  Rhode  Island  Hospital 
cares  for  45  bone  and  joint  cases  during  the  summer  months. 

The  facilities  for  the  care  of  active  cases  of  tuberculosis  amount 
in  the  aggregate  to  the  provision  of  1  bed  for  every  1100  persons  in 
the  general  population  or  1  bed  for  1.6  annual  deaths  from  tubercu- 
losis. This  ratio  is  below  that  to  be  recommended  as  ideal;  but  it 
is  high  as  compared  with  conditions  in  most  other  states  and  at 
present  the  actual  supply  of  patients  is  below  the  facilities  for  treat- 
ment, over  a  third  of  the  beds  at  Wallum  Lake  having  been  empty 
during  the  past  two  years.  This  condition  is  in  part  due  to  the 
real  decrease  in  tuberculosis  incidence  since  1917,  but  it  is  quite 
certain  that  there  remain  in  Rhode  Lsland  tuberculosis  patients 
needing  sanatorium  treatment  more  than  sufficient  to  fill  Wallum 
Lake  twice  over,  if  the  medical  and  nursing  machinery  of  the  state 
were  sufficiently  developed  to  get  them  there. 

The  admission  rate  to  hospitals  and  sanatoria  rose  for  the  state 
as  a  whole  from  92  per  100,000  population  in  1910  to  153  in  1918 
and  fell  again  to  133  in  1919,  which  is  an  exceedingly  good  figure  as 
compared  with  other  states.  Comparing  different  districts  within 
the  state,  it  appears  that  Providence  has  the  highest  admission 
rate  (135),  while  the  rate  for  Cranston  falls  to  44.  A  better  measure 
of  the  degree  of  success  in  hospitalization  is  the  ratio  of  admissions 
per  100  annual  deaths.  This  figure  too  is  highest  in  Providence 
(69),  with  Woonsocket  and  Central  Falls  next  (each  64),  Pawtucket 
and  Newport  next  (each  56),  the  smaller  towns  next  (50),  and  Crans- 
ton last  (46),  the  degree  of  hospitalization  effected  varying  di- 
rectly with  the  general  efficiency  of  clinic  and  nursing  service. 

The  first  serious  obstacle  to  success  in  sanatorium  treatment  is 
the  relatively  late  stage  of  the  disease  at  which  patients  are  ad- 
mitted. We  may  hope  for  a  cure  in  75  per  cent  of  the  incipient  cases 
admitted,  in  50  to  60  per  cent  of  the  moderately  advanced  and  in 
less  than  40  per  cent  of  the  far  advanced  cases.  The  fact  that  only 
from  1  to  7  per  cent  of  the  cases  admitted  at  Wallum  Lake  fall  in 
the  incipient  class  is  the  first  handicap  with  which  this  institution 
(in  common  with  most  others  of  its  class)  must  deal.  A  second 
handicap  is  the  short  time  for  which  patients  will  continue  treat- 
ment.    The  average  period  of  residence  for  sanatorium  cases  be- 

76, 


tween  1910  and  1917  was  156  days,  while  the  most  successful  sana- 
toria keep  their  patients  for  an  average  of  six  months  or  more. 
About  one  half  of  the  patients  at  Wallum  Lake  leave  against  advice. 

In  spite  of  these  handicaps  two-thirds  of  the  patients  leave 
Wallum  Lake  with  definitely  improved  health;  but  when  they  re- 
turn to  the  unhygienic  condition  of  home  life  many  of  them  quickly 
relapse.  The  admirable  statistics  published  by  Dr.  Barnes  in  the 
reports  of  the  State  Sanatorium  up  to  1917  make  possible  an  un- 
usually full  survey  of  the  ultimate  fate  of  the  discharged  patients. 
It  appears  that  about  25  per  cent  of  all  cases  discharged  make  a 
fairly  permanent  cure,  being  alive  and  at  work  after  an  average 
period  of  five  years  from  the  time  they  leave  the  institution.  Fifty- 
nine  per  cent  are  dead,  8  per  cent  alive  but  not  able  to  work  and  6 
per  cent  have  been  lost. 

This  somewhat  disappointing  showing  is  by  no  means  unusual, 
although  the  results  accomplished  at  Saranac  Lake  and  at  the  Gay- 
lord  Farm  Sanatorium  in  Connecticut  indicate  that  under  the  most 
favorable  conditions  half  or  two-thirds  of  a  series  of  sanatorium 
cases  can  be  saved  instead  of  one-quarter. 

If  sanatorium  treatment,  in  Rhode  Island  or  elsewhere,  is  to  be 
made  really  effective  three  things  are  necessary.  The  disease  must 
be  detected  promptly  and  patients  admitted  to  the  sanatorium  in 
an  early  and  curable  stage.  They  must  be  kept  in  the  institution 
until  the  disease  process  is  definitely  arrested.  And  after  discharge 
they  must  be  kept  under  supervision  and  provided  with  living  and 
working  conditions,  under  which  a  maximum  of  self-support  may 
be  achieved,  with  the  possibility  of  maintaining  a  reasonably  favor- 
able hygienic  regimen.  The  first  of  these  ends  must  be  attained 
chiefly  by  the  building  up  of  more  effective  clinic  and  public  health 
nursing  service  and  by  the  education  of  the  practising  physicians  of 
the  state  in  the  diagnosis  of  tuberculosis.  It  is  essential,  however, 
both  in  getting  patients  to  a  sanatorium  and  in  keeping  them  there, 
that  the  institution  be  made  as  attractive  as  possible  from  a  psycho- 
logical standpoint  and  that  every  facility  should  be  provided  for 
the  contact  with  family  and  friends  which  alone  makes  exile  from 
home  bearable  for  the  tuberculous  patient.  In  this  connection  it 
is  suggested  that  the  Rhode  Island  Tuberculosis  Association,  which 
has  always  felt  a  deep  interest  in  the  State  Sanatorium,  could  ren- 
der an  unusually  important  service  by  supporting  a  medical  social 
worker  at  Wallum  Lake  to  care  for  the  personal  side  of  the  life  of  the 

77 


patients  and  by  developing  some  means  of  transportation  service 
which  would  make  it  possible  for  the  friends  of  patients  to  visit 
them  conveniently  at  Wallum  Lake.  As  a  prerequisite  to  the  full 
development  of  this  later  service  it  would  be  necessary  to  secure 
from  the  state  legislature  funds  for  the  improvement  of  the  high- 
way between  Pascoag  and  Wallum  Lake  which  is  almost  impassable 
for  four  to  six  months  of  the  year. 

The  public  health  nurse  is  the  third  essential  factor  in  the  scheme 
of  tuberculosis  control;  and  here  too  Rhode  Island  is  reasonably 
well  off  as  compared  with  other  states,  though  falling  far  short  of  a 
desirable  ideal.  There  are  105  public  health  nurses  in  the  state, 
a  ratio  of  one  nurse  to  5800  persons.  It  requires  one  nurse  to  1500 
or  2000  persons  to  give  really  adequate  service.  Providence  has  1 
nurse  for  every  3600  persons,  being  far  ahead  of  any  other  com- 
munity. Westerly  and  the  Pawtuxet  Valley  stand  next  with  about 
5000  persons  per  nurse.  Woonsocket  and  East  Providence  have 
about  7000  persons  per  nurse,  Pawtucket  and  Central  Falls  about 
11,000  and  Cranston  over  14,000;  while  Newport  County  and  other 
districts  embracing  a  population  of  57,000  have  no  organized  public 
health  nursing  service. 

In  Providence,  Pawtucket,  Woonsocket,  the  Pawtuxet  Valley 
and  East  Providence  tuberculosis  cases  are  cared  for  by  special 
tuberculosis  nurses  while  in  the  other  communities  the  generalized 
district  plan  of  nursing  prevails.  The  seven  tuberculosis  nurses  of 
the  Providence  District  Nursing  Association  are  doing  admirable 
work.  Their  records  are  unusually  complete  and  reveal  evidence  of 
service  of  a  high  order.  They  have  themselves  discovered  about 
half  of  all  the  contact  and  suspicious  cases  for  which  they  care,  as 
well  as  14  per  cent  of  the  positive  cases.  Each  nurse  cares  for  ap- 
proximately 225  cases  in  a  year  and  makes  an  average  of  about  10 
visits  per  case.  The  latter  figure  is  too  low,  as  must  be  expected 
with  so  small  a  nursing  force.  A  special  study  of  500  consecutive 
positive  cases  to  indicate  the  nature  of  the  actual  results  achieved 
shows  that  83  per  cent  of  the  patients  were  placed  in  a  sanatorium 
or  hospital  and  kept  there  for  a  reasonably  satisfactory  period  and 
that  12  per  cent  were  cared  for  at  home  under  adequate  sanitary 
and  hygienic  conditions.  Sixty-four  per  cent  of  these  500  patients" 
were  definitely  improved  in  condition  at  the  end  of  a  year  and  only 
14  per  cent  were  dead. 

78 


In  comparing  the  adequacy  of  tuberculosis  nursing  service,  the 
best  criterion  is  perhaps  the  ratio  of  visits  to  tuberculosis  patients 
per  year  per  1000  population.  On  this  basis  the  Pawtuxet  Valley 
district  (West  Warwick  and  Coventry)  shows  up  best,  with  85 
visits  per  1000  population;  and  the  work  of  the  nurse  at  Riverpoint 
is  in  every  way  deserving  of  the  highest  praise.  Both  clinic  and 
nursing  service  at  this  little  health  center  are  models  of  their  kind. 

Providence  comes  next  with  65  visits  per  1000  population;  Woon- 
socket  next  with  43;  Pawtucket  next  with  about  30;  twelve  small 
towns  which  employ  generalized  nurses  next  with  24;  and  East 
Providence  last  with  19.  In  New  Haven,  nine  nurses,  serving  a 
population  of  164,000,  make  127  visits  to  tuberculosis  cases  per 
1000  population. 

In  regard  to  the  quality  of  the  tuberculosis  nursing  service  in 
Rhode  Island  there  is  no  legitimate  criticism  to  be  made,  except  in 
the  case  of  certain  of  the  small  towns  where  the  generalized  nurses 
do  not  appear  to  have  grasped  the  essentials  of  the  problem.  In 
general  however,  it  is  quantity,  not  quality,  which  is  deficient;  the 
nurse  at  Pawtucket  with  305  cases  to  care  for  is,  for  instance,  under- 
taking a  clearly  impossible  task.  It  is  no  wonder  that  79  per  cent 
of  the  cases  cared  for  by  this  nurse  were  positive  cases  and  that  22 
per  cent  of  them  died  (as  compared  with  53  per  cent  positive  cases 
and  14  per  cent  deaths  in  Providence) ;  for  in  a  population  of  100,000 
a  single  tuberculosis  nurse  can  only  attend  to  the  most  critical  and 
advanced  cases.  The  State  Board  of  Health,  the  Rhode  Island 
Tuberculosis  Association  and  other  interested  agencies  should  do 
everything  in  their  power  to  aid  in  the  development  of  public  health 
nursing  where  it  is  now  wholly  lacking  or  notably  deficient  in  amount, 
— notably  in  Pawtucket  and  Central  Falls,  in  East  Providence,  in 
Cranston  (where  only  7  visits  are  made  per  1000  population)  and 
in  Newport  County  (where  there  is  no  tuberculosis  nursing  service 
at  all).  The  organization  of  a  Division  of  Public  Health  Nursing 
under  the  State  Board  of  Health  should  prove  of  the  greatest  value 
in  stimulating  and  co-ordinating  the  nursing  service  of  the  state. 

■  Finally,  there  remains  to  be  considered  the  part  played  in  the 
anti-tuberculosis  campaign  by  voluntary  associations,  and  particu- 
larly by  the  Rhode  Island  Tuberculosis  Association  and  the  Provi- 
dence Tuberculosis  League.  Both  these  organizations  have  ren- 
dered splendid  service  to  the  cause  and  their  work  is  full  of  promise 
for  the  future.     Past  achievements  of  these  organizations  along  the 

79 


lines  of  research,  of  education,  of  legislative  propaganda,  of  or- 
ganization and  of  direct  service,  have  been  discussed  above;  it  re- 
mains only  to  consider  certain  of  the  more  important  lines  of  future 
activity.  Both  the  Association  and  the  League  will  obviously  con- 
tinue their  admirable  service  in  the  stimulation  of  clinic  and  nursing 
organization  and  in  the  education  of  school  children  through  the 
Health  Crusade  movement.  In  addition,  however,  there  are  spe- 
cial new  phases  of  the  tuberculosis  program  which  offer  a  call  for 
unusual  service  to  both  organizations. 

For  the  Rhode  Island  Tuberculosis  Association  the  three  most 
important  tasks  would  appear  to  be  the  following: 

A.  The  organization  of  a  legislative  campaign  to  secure  the  crea- 
tion of  Divisions  of  Tuberculosis  and  of  Public  Health  Nursing 
under  the  State  Board  of  Health  with  adequate  funds  for  their  sup- 
port (at  least  $15,000  a  year  each),  and  to  obtain  an  appropriation 
for  improving  the  road  to  Wallum  Lake. 

B.  The  systematic  attempt  to  develop  and  improve  clinic  and 
nursing  facilities  throughout  the  state,  particularly  in  Pawtucket, 
Woonsocket,  Cranston  and  Newport  County.  This  work  should  be 
vigorously  pushed,  without  waiting  for  the  appointment  of  the 
State  Director,  and  later  carried  forward  in  co-operation  with  him. 
The  ideal  of  1-2  clinic  visits  and  5-10  nursing  visits  per  month 
per  1000  population  might  be  set  as  a  fair  standard  of  reasonably 
adequate  service. 

C.  The  support  of  a  medical  social  worker  at  Wallum  Lake  and 
the  provision  of  special  transportation  service  which  will  facilitate 
the  visiting  of  patients  by  their  families  and  friends.  The  officers 
of  the  association  should  not  consider  their  duty  done  until  all  the 
beds  at  Wallum  Lake  are  filled,  and  until  the  average  period  of 
residence  is  over  six  months. 

For  the  Providence  Tuberculosis  League  there  are  four  oppor- 
tunities which  seem  to  offer  rich  possibilities: 

A.  The  organization  of  a  vigorous  campaign  for  the  establish- 
ment of  a  Division  of  Tuberculosis  in  the  municipal  health  depart- 
ment of  Providence,  with  a  Medical  Director  whose  duty  shall  be 
to  coordinate  clinic  and  nursing  services,  and  to  maintain  super- 
vision over  all  cases  of  tuberculosis  within  the  city  limits. 

B.  To  offer  to  the  private  physicians  of  Providence  the  far- 
reaching  advantages  of  a  medical  consultation  service. 

8o 


C.  To  conduct  a  survey  of  industrial  conditions  in  their  relation 
to  tuberculosis  and  to  formulate  a  program  of  industrial  medical 
and  nursing  service  to  combat  this  disease. 

D.  To  conduct  (perhaps  with  the  cooperation  of  the  Rhode 
Island  Tuberculosis  Association)  a  study  of  the  problems  of  occu- 
pational therapy  and  to  consider  the  possibility  of  establishing  in- 
dustrial colonies,  supervised  workshops  or  model  housing  plans 
which  will  make  it  possible  for  the  arrested  case  to  maintain  the 
ground  that  has  been  gained  after  discharge  from  the  sanatorium. 

The  last  three  of  these  suggestions  are  all  prominently  included  in 
Dr.  Washburn's  plans  for  the  development  of  the  League;  and  the 
vision  which  has  been  shown  in  formulating  these  plans  is  deserving 
of  the  highest  praise. 


The  neglect  of  tuberculosis  by  public  authorities  is  a  phenomenon 
of  general  occurrence.  There  are  fashions  in  public  health  as  in 
other  things.  Tuberculosis  work  began  with  great  vigor  twenty 
years  ago  and  has  slackened  its  activities  during  the  past  decade. 
The  health  officer,  the  physician  and  the  public  must  be  reawakened, 
— reconvinced  that  tuberculosis  is  a  terrible,  and  largely  a  pre- 
ventable, disease. 

The  attention  of  public  health  workers  throughout  the  country  is 
focused  with  the  keenest  interest  upon  the  little  town  of  Framing- 
ham,  where  a  small-scale  demonstration  of  tuberculosis  control  is 
being  conducted  with  such  marked  success.  Rhode  Island  has  the 
opportunity  of  conducting  a  similar  demonstration  in  a  whole  state, 
yet  a  state  compact  enough  to  make  possible  easy  and  complete  con- 
trol. The  essential  elements  of  sanatorium  facilities,  clinics  and  nurs- 
ing service  are  in  existence  and  could  be  expanded  and  coordinated 
to  form  a  machine  of  power  and  effectiveness;  and  the  present  exces- 
sive tuberculosis  death  rate  which  lays  such  a  heavy  burden  on 
the  state  is  a  definite  challenge  to  action.  If  this  death  rate  could 
be  reduced  twenty  points  per  100,000  (to  the  level  of  the  correspond- 
ing death-rate  in  Connecticut)  it  would  mean  the  saving,  each  year, 
of  120  lives,  worth  to  the  community  over  $600,000.  Such  a  reduc- 
tion is  possible  and  practicable.  Is  the  undertaking  not  worth  a 
serious  attempt? 

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